Audio Visual Consultancy, Design, Installation and Support
The furniture used in institutions could be very much indicative of their regime and values. It demonstrates how a system regards the individual and gives clear hints about the expected behaviours of service users. Nowadays, more than sixty years from the psychiatric reform, the messages tend to be mixed. In the UK, after the innovative yet risky period of normalisation where safety was compromised in understaffed facilities, we witness a return towards more conservative approaches. This, however, does not necessarily constitute the case in many European countries such as the Netherlands, where more integrated approaches enable the country to tackle dangerousness in a more systemic way.
To some extent, these approaches provide the potential to reduce some anti-ligature specs in psychiatric environments. In the rest of the world, there is discussion on where mental health goes, with eminent reforms in many countries from New Zealand, to Eastern Europe or Israel to name but a few.
An interesting element of this variety of approaches is that there has not yet been a linear path of progress when it comes to mental health. It is important, therefore, to have some knowledge of the past. This will enable us to be aware of what is truly innovative or what is an institutional element that finds its way back into the system. This is not only our way to avoid design being used to create new ‘modernised’ institutions but also our way to create products that constitute true innovations that are applicable to more than the limited geographical context of the UK. In other words, true innovation can be very much welcomed across the borders. Even if mental health services present distinct differences from place to place, mental health pathology is universal, and clever solutions that respond to the actual problem will be very much appreciated in several contexts.
Design for de-institutionalisation
Back in the 1960s, architects Baker, Davies and psychiatrist Sivadon revolutionised the concept of designing for the entire spectrum of mental health environments. Their elaborate and comprehensive recommendations in the WHO publication ‘Psychiatric services and architecture’, they deal with furniture. They developed a pioneering concept advocating the shift from prison-like to home-like forms for psychiatric hospitals and campaigned for the introduction of atmospheres and styles that were as domestic as possible. This innovative approach was backed by social theories, related to the therapeutic qualities of space as these were perceived at the time and was named ‘psychiatric architecture’.
The team’s recommendations for the WHO publication received limited appreciation in practice, and the reality in psychiatric hospitals remained that of the old institutional regime. With regard to furniture, this translated to the continuing use of immobile or very heavy pieces that have been associated with total institutions (Marcus 1993, Vavyli 1992). Yet, the idea of a haven for mental health was too good for psychiatrists to abandon. So it was reintroduced by Professor Amiel, in his concept of topotherapy, a new paradigm emphasising the therapeutic qualities of three dimensional space (Cole 1980, Amiel 1976). The design features that he introduced were closer to a hotel typology, with emphasis on bi-polar pairs that used antitheses for therapeutic purposes.
Soon after, H. Goodman, chief architect of the British Ministry of Health came with a new approach. He advocated the need for mental health facilities to get rid of any institutional references that reflected incarceration.
Instead, he insisted on normal furniture and carpeting, prioritising a normal environment as higher than security. During that period in Britain there was a growing body of specialists that considered many of the anti-ligature devices as ‘unnecessary and self-defeating’ (Goodman 1976). This was a period where a strong criticism of the hospital environment, the anti-psychiatry movement and experiments such as the one by Rosenham, which proved the inability of clinicians to distinguish between real and pseudo patients in psychiatric admissions, cast considerable doubt over psychiatric institutions. Yet, despite the several approaches that sprang during this period one common factor rose and has not been questioned since: environment mattered and interior design including furniture has been an element to be considered seriously.
More research justified this further. Poor environments that showed neglect as well as frightening places have been connected to absconding (Sainsbury Centre 1998). In addition, the environment conveys messages to staff and service users as far as it concerns expected behaviours (Griffin et al 1969; Malkin 1992). Finally, staff and service users were aware of their environments and the value that these environments had towards the therapeutic procedure (Chrysikou 2014).
So, what’s next?
Comfortable quality furniture that is durable, safe and light, domestic looking bathroom fittings and fixtures that are of good quality and windows without bars that can be opened for ventilation by the user, are but some of the details that are available nowadays to the designer. Modern materials could be used for increased durability and lightness. These are actually much safer and offer unlimited options to creativity. On the contrary, the heavy furniture offers only a fake sense of safety that professionals back in the 1950s knew very well. What appears as a heavy, unliftable object in the eyes of an inexperienced mental health designer could be a dangerous object in the hands of a service user in crisis.
The frustration can arm the individual with force and willpower that enables lifting the heavy object and throwing it or using it as a barrier.
We should not allow neglect, tough budgets for mental health, or a sense of ignorance on the effect that space can have on the wellbeing of service users and staff and therefore in the quality of care. Around the world, health professionals and architects are not necessarily aware of the true implications and stakes when they still position themselves between the two opposing poles of mental health frameworks. This constitutes from one side, those who advocate that architecture could assist staff in the task of preventing service users to harm themselves or others. This tends to become more and more demanding as a result of increasingly tough budgets, especially on skilled staff. As far as it concerns design, this translates to design for anti-ligature and places emphasis on the security of the facilities.
The remaining aspects of the mental health professionals’ job description, such as engaging with clients in conversations and activities, are not directly addressed by this approach. In more detail, the anti-ligature considerations tend to be met either by creating sacrificial layers that cannot stand pressure (such as Velcro curtains or collapsible curtain rails) or by objects that can be designed and built to withstand violence (such as fixed or built furniture, unbreakable containers for audiovisual equipment such as TVs, use of toughened glass), or fabrics that are easy to clean (such as vinyl). In short, maintenance and durability are key to this approach.
The other approach is opposed to this framework and considers that heavy, fixed furniture and padded cells have been, in design terms, linked to the definition of institutional space. The gradual progress in the medical and pharmaceutical domain, as well as the techniques of complimentary to psychiatry professions such as therapists and psychologists, questioned the need to include all these restrictive elements. To them, these restrictions had to be imposed at times that both society and medicine did not provide the options available today. This trend is proposing good quality, durable furniture that demonstrates to service users that they are taken care of in an environment that shows them respect and trust and that caters for their needs and wellbeing.
Such examples could include gigantic interactive touch screens fitted into the walls of rooms, even in seclusion. From these, service users can communicate with staff, write, draw, watch videos or listen to music defining the degree and type of communication or stimuli they are willing to have. However, even less hi-tech solutions can have an impact in service users’ wellbeing, by increasing their personalisation and choice in the environment. This can be achieved through their ability to interact with the configuration of furniture in their rooms, which dictates for mobile objects that are flexible to manoeuvre. Therapeutically, this can be an excellent tool for therapists to access behaviours and progress, as passivity is often linked to ill health. Similarly, in common areas, pieces of furniture that clients can lift and re-arrange to form social groups are indicative of social progress. Even aggression can be communicated through service users’ use of furniture allowing staff the opportunity to interact according to the messages they receive.
Of course the type and specifications of furniture is only an aspect of it. Other aspects can be the arrangement of the furniture in place according to how sociofugal or sociopetal it is, the amount of furniture according to parameters such as function, territoriality, ambience, sense of crowding and space blockage, accessibility etc. However, these very important issues are a whole new topic that is beyond the scope of this article.
Within the Design In Mental Health Network, we are very much aware of the value of the environment for mental health. We are even more aware of the benefit from the dialogue and the continuous learning process on all aspects of mental health design. For that reason, we are open to all specialties involved in the process, including the service users to actively join us. The exchange of ideas and the grounds for discussion is the core of many of our initiatives, such as the Better Bedroom initiative or our conference and exhibition that put mental health design where it should be: on the spotlight of innovation.
James Feindt, Marck Aghnatios and Alistair Fleming look at the opportunities of migrating care from hospital to the home environment, as well as the challenges it creates