Therapeutic Landscapes and Psychiatric Care Facilities

Therapeutic Landscapes and Psychiatric Care Facilities: Comparison

Please note this is a comparison between Version 1 by Lydia Oeljeklaus and Version 4 by Lindsay Dong.

Healing environments have been defined as therapeutic landscapes (TL), where the physical and built enhe environments, social conditions and human perceptions combine to produce an atmosphere which is conducive to healing. The environment in mental-health in healthcare facilities can influence health and recovery of service users and furthermore contribute to healthy workplaces for staff. The physical (built and natural), social, and symbolic dimensionsconcept of the therapeutic landscape can have positive and negative impacts. Therefore, the needs and characteristics of the different stakeholders have to be considereds seems to be a promising approach in this context.

physical
built
natural
social and symbolic environment
mental disorders
mental health
psychiatric hospital
therapeutic landscape

1. Introduction

1.1. Environment, Health, and Well-Being

The environment has a significant impact on health ^[1][2][1,2]. Global research emphasises the positive relationship between direct experiences of natural environments and a wide range of health benefits ^[1][3][4][5][1,3,4,5], in addition to the key role nature plays in creating healthy environments ^[6][7][6,7], and in relation to an overall healthy society [8]. Direct and continuous contact with nature can be preventive and health promoting ^[3][4][9][3,4,9], e.g., by increasing physical and mental well-being or reducing stress ^{[10][11][12][13][14][15][16][17]}[10,11,12,13,14,15,16,17], and promoting social inclusion and social cohesion ^[5][18][5,18]. In addition, ecosystems provide elemental services to humans, such as providing resources, regulating clean air and water, supporting nutrient cycling, and providing opportunities for cultural and recreational experiences [19]. Ecosystems can therefore have an impact on mental health (MH) [20], e.g., by providing spaces for physical activity and social contact ^[21][22][21,22].

1.2. The Concept of Therapeutic Landscapes

In the context of a healthy environment, the concept of therapeutic landscapes (TL) was introduced and coined by Gesler from 1992 [9]. The aim is to explore why certain environments appear to contribute to a “healing sense of place” ^[9][23][9,23]. Healing environments have been defined as TL, “where the physical and built environments, social conditions and human perceptions combine to produce an atmosphere which is conducive to healing” [24] (p. 96). Within the concept, four overarching elements can be summarised that are characteristic of a TL [3], namely: (1) natural environments (e.g., green and blue spaces), (2) artificial/built environments (e.g., design features), (3) social environments (including sense of place, attitudes, and values) and (4) symbolic environments (including regional identity, religious places). Therefore, it is important to understand the physical and social health-promoting qualities of a given space, and also the more subjective ways in which people might interpret and use it differently ^[25][26][27][25,26,27].

TL have been examined at different environmental levels, from large-scale (e.g., countryside), to mesoscale (e.g., urban parks), and microscale environments (e.g., hospitals and clinics, gardens, buildings). Additionally, the scope has been further refined by focusing on diverse populations (e.g., different age groups, gender, cultures, physical abilities, and place-specific practices) ^[25][27][25,27]. Moreover, it is necessary to differentiate between TL in general and in specific settings ^[27][28][27,28]. In psychiatric care, in particular, two different levels of observation (psychiatric facility as a whole TL and specific elements within the psychiatric facility) must be considered [29].

1.3. Therapeutic Landscapes and Facility Design in Providing MH Care

1.3. TL and Facility Design in Providing MH Care

The clinical setting, especially inpatient psychiatric care, contributes substantially to MH ^[28][30][28,30]. Facility design, infrastructure, and architecture can both positively and negatively influence the health and recovery of service users (SUs) ^{[30][31][32][33][34]}[30,31,32,33,34] and contribute to healthy workplaces [28]. Nevertheless, perceptions and assessments of environmental factors can differ between medical staff and SUs [30]. The United Nations Convention on Rights of Persons with Disabilities (CRPD), which provides a framework for human rights-oriented change to MH services [35], is closely linked to the improvement in the environmental quality in psychiatric care. The concept of TL can make an important contribution to this improvement.

Curtis et al. [28] identified six relevant TL dimensions, namely “Respect and empowerment for people with mental illness”, “Security an surveillance vs. freedom and openness”, “Territoriality, privacy, refuge, and social interactions”, “Homeliness and contact with nature”, “Places for expression and reaffirmation of identity, autonomy and SUs choice”, and “Integration into sustainable communities”, amongst different groups of people related to an inpatient MH facility (cf. 591). These dimensions include: (1) respect for and empowerment of people with mental illness and the extent to which the environment in a MH facility respects the personality, preferences, culture, and religion of SUs; (2) the conflict between the need to control and restrict SUs and the goal of promoting human needs and individuality; (3) the need within a MH facility for dedicated spaces (e.g., for social interactions) without coming into contact with medical staff; (4) a homely atmosphere and the use of natural elements to promote contact with nature; (5) the need to provide facilities that promote the MH of SUs while respecting individuality and diversity and enabling self-directed living and participation in treatment decisions; and (6) the promotion of (social) reintegration of people with mental illness through good networking of MH care facilities with the community environment [28].

2. Therapeutic Landscapes and Psychiatric Care Facilities

Within the physical dimension, design features and their perception are included. A unanimous opinion was the need for a caring, homelike, and pleasant environment. In this regard, a balance between a pleasant and useful environment, evenly offering privacy and safety for SUs and staff, is necessary. Moreover, a facility should enable possibilities for reflection without disturbance but also positive distraction by the TL. Hackett et al. ^[36][52] found similar results regarding the physical environment for youth SUs in different healthcare settings. Service providers and youth SUs mentioned a welcoming environment, i.e., being bright, decorated, and youth-friendly, to be important for high quality care. Moreover, youth SUs asked for privacy and autonomy in decorating their own rooms. An open view and access to nature were mentioned as important aspects of the physical environment by some of the referred studies. Visual and physical access to nature have been found to be important for healthcare facilities in general, as being not only beneficial for the physical and mental health of SUs, but also that of staff ^[37][53]. In the same way, the provision of daylight within the facility enhances SUs’ and staff’s physical and mental health ^[37][53]. In the study by Shepley et al. ^[38][48], there was an awareness for the need for daylight, but no idea of realisation. According to Sherif et al. ^[39][54], daylight and the view from a window can be influenced and regulated by the shape of the slats on blinds. In this regard, the possibility of personal control of the individual’s environment can benefit MH additionally ^[37][40][53,55]. Moreover, special designs/furniture for certain SUs, e.g., geriatric or forensic SUs, are needed. According to Karlin and Zeiss ^[41][56], an issue that must be considered is the design of the interior in such a way that goals of stimulation are addressing the right SU, while fostering an optimistic sense about hospitalisation at the same time. It is desirable to design psychiatric facilities that align with different SU demands, but this may be not completely feasible in every case ^[33][41][33,56].

The provision of rooms for social connection and activities with other SUs, carers, and staff, and to practice religion, is important and directly connected to a conducive social environment. This is in line with results from Jovanović et al. ^[42][62], who found that family rooms off ward were associated with psychiatric SUs’ treatment satisfaction. Most of the investigated wards in this study were part of general hospitals; hence, it may be easier to provide social places off-ward than at solely psychiatric facilities. Nonetheless, it is likely that the availability of specific places to meet family and friends, apart from communal rooms, enhances SU treatment satisfaction and thus well-being. In this regard, informal carers’ demands, such as accessibility to the facility and places to connect with their cared-for relatives, are essential and enhance social interactions ^[37][53]. Moreover, multiple-occupancy rooms can provide the opportunity for social interaction between SUs ^[43][44][63,64]. In addition, Ulrich et al. ^[45][65] mentions the stress-reducing effects of communal areas with movable seating and ample space, which allows the regulation of relationships. Providing unlocked outdoor gardens and rooms with a view of nature can foster stress reduction by offering pleasant places to seek privacy or socialise ^[45][65]. Karlin and Zeiss ^[41][56] recommend designing social places so that SUs can control their level of social contact, retreat, or form new relationships. The need for areas and (sportive) activities, where the mental illness is not present for SUs or visible for others, allowing them to adapt to roles apart from being a SU, was also outlined by McGrath and Reavey ^[46][66]. Regarding (meaningful) activities or areas, it is important to take SUs’ preferences into account. As shown by Parkinson et al. ^[47][67], activities, i.e., horticulture, are not meaningful per se. SUs perceived horticulture only as beneficial when related to the individual’s interest ^[47][67].

A relevant aspect of the social dimension is a balance between sense of safety, privacy, autonomy, and freedom, e.g., to allow everyday choices and prevent the feeling of being locked up. Similar to the results of this qualitative meta-analysis, SUs in several studies repeatedly expressed feeling locked-up and described the environment as prison-like ^[36][44][46][52,64,66]. Clear boundaries and options on how to use private and common places, e.g., no formal SU–staff interaction in private rooms, can be supportive for treatment, but need to fit SUs’ demands. Although in the present qualitative meta-analysis SUs expressed a desire for (great) leeway, Maloret and Scott ^[48][68] showed that specific SU-groups (SU with autism spectrum disorder and an acute panic disorder) need daily routines and structure. Single-SU rooms are associated with privacy ^[37][53] and autonomy through the sense of control of the SUs’ own environment ^[37][44][53,64]. A review of MH aspects of the built environment affirms the importance of indirect control of the built environment through social interactions, in a variety of settings ^[40][55]. In one included study, women felt less safe in communal spaces ^[49][44]. In contrast, Jovanović et al. ^[42][62] found that SU treatment satisfaction is associated with mixed-sex wards. Consequently, further research is needed as previous research stated both advantages and disadvantages of mixed-sex wards ^[50][51][69,70]. Regarding safe spaces, staff have to be considered ^[52][53][71,72], because about 24–80% of MH care staff experience violence at least once in their career ^[54][73].

From SUs’ perspectives, lifelike environments are preferred over restrictive ones, albeit staff’s demands to execute their working tasks need to be considered. This matches previous findings of a preference for lifelike units that are associated with beneficial MH outcomes ^[55][74]. Earlier-mentioned elements, such as daylight, music, and airflow ^[56][75], hospital gardens ^[57][76], and separate places for staff restoration and communication ^[37][53], can also enhance staff’s work satisfaction.

Concurrently, social relationships are of significant importance, as, e.g., SU–staff relationship can have a direct effect on SU well-being. The physical and social dimensions act as facilitators and barriers of the therapeutic value, i.e., symbolic dimension, of the psychiatric facility. An unsuitable physical environment can severely impair aspects of the social dimension, such as quality of care and the feeling of safety, and may damage the person-centred therapeutic process ^[44][64]. Additional barriers are the associated stigma through the facility design, in addition to SUs’ and carers’ subordinate position within the facility. This was also mentioned by McGrath and Reavey ^[46][66], where the entire environment and, in particular, locked doorways, reflected the commonly perceived stigmatisation and caused a feeling of devaluation.