Aesthetic considerations in long-term care and psychiatric facilities: Ideas from environmental psychology

Presentation guide and supplementary notes

Eddy M. Elmer

Simon Fraser University, Fall 2001

Objective

Both research and anecdotal evidence have suggested that the aesthetic features of one's physical environment can have a significant impact on mental and physical¹ well-being. This presentation will draw on evidence from the field of environmental psychology to illuminate how aesthetic features such as colour, texture, furnishings, spatial design, and aesthetic variety can affect such various psychological variables as emotion, mood, cognitive function, attention, self-perception (including individuality), self-efficacy, and altruism. This presentation will be applied to (interior) design of long-term care and psychiatric facilities, particularly those for seniors.

Defining terms

"Environmental psychology": This is a relatively new, highly interdisciplinary field that examines the relationship between environments and human behavior.

"Environment" includes natural settings, social settings, built environments, learning environments, and information environments.

Several research areas^2,3:

1. "Attention": How we notice the environment
   
2. "Perception and cognitive maps": Our perception of the environment is linked with our memories, emotions, thoughts, and ideas to form "cognitive maps"
   
3. "Preferred environments": We prefer environments that:

1. make us feel confident
   
2. make us feel competent
   
3. allow us both to make sense of them and interact with them
   
4. are coherent
   
5. are legible (environments which one can explore but not get "lost" in)

Well-being and self-efficacy are associated with "preserving, restoring, and creating a preferred environment".

4. "Environmental stress and coping": Noise, climate, failure of preference, prolonged uncertainty, lack of predictability, and stimulus overload
   
5. "Environmental participation": Citizen involvement in environmental design, management, and restoration
   
6. "Conservation behaviour"

"Aesthetics" is the study of the psychological responses to beauty and artistic experiences (this is the psychological, as opposed to the philosophical definition).

Aesthetics and facilities

• important early observations by Goffman⁴:

• defines "total institutions"—"Every institution captures something of the time and interest of its members and provides something of a world for them; in brief, every institution has encompassing tendencies. When we review the different institutions in our Western society, we find some that are encompassing to a degree discontinuously greater than the ones next in line. Their encompassing or total character is symbolized by the barrier to social intercourse with the outside and to departure that is often built right into the physical plant. . .These establishments I am calling total institutions. . ." (p. 4.)

• my (arguable) contention: facilities for the aged—whether or not we like to admit it—are total institutions
• total institutions aim to control, however subtle that control may be
• control can be physical (e.g., restraints) or psychological (e.g., depersonalisation)
• psychological control can be achieved through physical aesthetics
• Klaassen: "Seniors want a home, not an institution"⁵; see also Day⁶ and Gunter⁷
• Hiatt: "Many facilities currently meet code minimums but look and feel abominable."⁸
• Malkin: "The basic issue to be addressed by any design is enabling the resident to function at his or her optimal level."⁹
• much environmental research is interdisciplinary; many researchers adapting results from one type of environment to another (e.g., from correctional facility to nursing home and vice versa)
• in general, it seems that regardless of age, we all have certain basic environmental preferences
• with seniors in facilities, we want to take extra care to ensure these preferences are accommodated

General design considerations

• rooms and places as a whole can facilitate mood changes¹⁰
• remodelling study: 5-week post-remodelling showed overall reductions in pathological behaviours¹¹
• most interior design research is on facilities for chronically ill or physically disabled seniors without psychiatric problems¹²
• good design helps give residents a sense of being in a "safe haven"¹³

Interior architectural style

• adopt familiar styles, such as Victorian; see Klaassen¹⁴

Colour

Birren on moods¹⁵

• "It is to be granted, of course, that direct connections exist between the brain and the body and that reactions take place independently of thought or deliberation"

• warm/active vs. cool/passive
• light/active vs. deep/passive
• warm: environment contact
• cool: inward withdrawal
• red colours—ANS stimulation due to longer wavelengths
• bluer colours—sedating due to shorter wavelengths

Other colour research and suggestions

• generally, mood of colours depends not only on the colour, but also the saturation and how it is used (including how much of it is used)
• institutional blue-green is calming, promotes feelings of security and tenderness¹⁶, and relieves nausea, but may also adversely affect mood (e.g., sadness, depression, fatigue)¹⁷
• white: more headaches, nausea than red or blue¹⁸
• bright colours are a poor choice; can promote/exacerbate agitation, restlessness, anxiety, confusion, depression; may affect psychosis²⁰
• highly-waxed floors are inappropriate²¹
• colour selection to promote stimulus variety²²

Texture

• textures add variation to tactile sensations²³, which can be comforting, etc.
• eliminate vinyl-based floor coverings and replace with carpeting—everywhere²⁴

Lighting

• regular fluorescent lighting inappropriate—flickers, causes tearing, headaches, and general inattentiveness¹⁵
• fluorescent lighting cold, artificial; sense of sterility and isolation; note Hopper painting, Hotel Lobby (1943)
• full-spectrum lighting better
• natural lighting critical
• poorer ratings of subjective well-being when more than 10 ft from a window for relatively long periods each day²⁶; obstructing screens also a concern
• windows ideally:

1. large, low
2. view from windows also critical²⁷; best: windows providing sunlight and good view (either of people²⁸—for short-term stay—or nature²⁹ for longer-term stay); worst: few large windows providing daylight only (no sunlight) and a poor view

• windows and boredom reduction³⁰
• blinds can be critical in controlling exciting behaviour³¹

Floorings, furnishings

• interesting walking paths can affect mood³²; can provide outlet for anxiety and restlessness³³
• Homme, 2000—importance of chairs: "This research indicates that chairs are meaningful in human experience in that they fulfill four basic psychological needs. Chairs fulfill the need to define and maintain a sense of territory, identity, visual order and comfort. Consequently, chairs hold meaning in human experience in a conceptual dimension beyond that of the functional or aesthetic."³⁴
• general arrangement; note Hopper painting, Chair Car (1965)

Spatial design

• avoid tight spaces; can be constricting, isolating; note Hopper painting, Hotel Room (1931)
• rooms should differ in size, shape, function
• vary interior design to provide themes and differentiation for rooms
• avoid repetitive patterns
• avoid long corridors
• added depth reduces psychological distress in more crowded areas (because it reduces social withdrawal)³⁵

Stimulus definition; environmental coherence; balance

• environmental stimuli should define spaces; this allows for mastery over territory and feelings of competence³⁶
• but also aim for environmental coherence³⁷; note Matisse painting, The Red Room (or Harmony in Red), 1908
• balance also key—calming; note Kennington interior painting, Each and Every Tuesday

Aesthetic variety

• again, variety can reduce boredom, passivity
• varying of bedspreads and draperies for personalisation³⁸
• variety can promote flow (cf. Csikszentmihaly)³⁹

Aesthetic paradox

• avoid paradox wherever possible⁴⁰
• can confuse patients with dementias and other cognitive difficulties
• may be overly stimulating

Familiarity

• people tend to prefer familiar rooms over decorative or "stylish" rooms (which, incidentally, are seen more as making statements about one's personality than as being "homey")⁴¹
• objects can cue and evoke behaviour⁴²
• familiar objects can facilitate psychological function, whereas innovative or modern objects can diminish skills⁴³

Introducing aesthetic change

• Sime: "It is not possible to create a place for building users solely by manipulating the physical environment on their behalf."⁴⁴
• one classic study: 300% increase in death rate among seniors who moved from an old facility to a "new, clean, stainless steel environment"⁴⁵
• Moye and moving⁴⁶

Suggested readings

Evans, G.W., & McCoy, J.M. (1998). When buildings don't work: The role of architecture in human health. Journal of Environmental Psychology, 18 (1), 85-94.

Garling, T., & Golledge, R. (Eds.). (1993). Behavior and environment: Psychological and geographical approaches. Amsterdam: North Holland.

Gelwicks, L. (1974). Needs, environmental design, and health care of the aged. In E. Seymour (Ed.), Psychosocial needs of the aged: a health care perspective (Revised Edition). Los Angeles: University of Southern California Press.

Kaplan, S., & Kaplan, R. (1982). Cognition and environment. New York: Praeger.

Spivack, M., & Tamer, J. (Eds.). (1984). Institutional settings: An environmental design approach. New York: Human Sciences Press.

Stokols, D., & Altman, I. (Eds.). (1987). Handbook of environmental psychology. New York: Wiley.

Teresi, J.A., Holmes, D., & Ory, M.G. (2000). The therapeutic design of environments for people with dementia: Further reflections and recent findings from the National Institute on Aging collaborative studies of dementia special care units. Gerontologist, 40 (4), 417-421.

Terwogt, M.M., & Hoeksma, J.B. (1995). Colors and emotions: Preferences and combinations. Journal of General Psychology, 122, 5-17.

Endnotes

1. It has also been suggested that the aesthetic features of an environment can have effects on physical states, including blood pressure, glucose levels, and immune function. For example, see: Gerard, R. (1957). Differential effects of colored lights on psychophysiological functions. Unpublished doctoral dissertation, University of California, Los Angeles. See also Wolfarth, H., & Sam, C. (1982). The effects of color psychodynamic environment modification upon psycho physiological and behavioral reactions of severely handicapped children. International Journal of Biosocial Research, 3, 10-38. This presentation, however, will focus directly on psychological variables, particularly since these are the variables that usually indirectly affect physical states. Please see me if you wish further details.
2. Garling, T., & Golledge, R. (Eds.). (1993). Behavior and environment: Psychological and geographical approaches. Amsterdam: North Holland.
3. Kaplan, S., & Kaplan, R. (1982). Cognition and environment. New York: Praeger.
4. Goffman, E. (1961). Asylums. New York: Anchor Books/Doubleday. [Detailed analysis of institutional life.]
5. Klaassen, P. (1990). Increased importance placed on resident-centered design. Provider, 16 (10), 43-44.
6. Day, K., Carreon, D., & Stump, C. (2000). The therapeutic design of environments for people with dementia: A review of the empirical research. Gerontologist, 40 (4), 397-416.
7. Gunter, B. (2000). Psychology of the home. London: Whurr Publishers
8. Hiatt, L.G. (1978, November-December). Architecture for the aged: Design for living. Inland Architect, 6-18.
9. Nursing Homes (1993). Looking good: What designs work best for residents. Nursing Homes, 42 (8), 18-23.
10. Hiatt, L.G. (1987). Environmental design and mentally impaired older people. In H.J. Altman (Ed.), Alzheimer's disease: Problems, prospects, and perspectives. New York: Plenum.
11. Stahler, G.J., Frazer, D., & Rappaport, H. (1984). The evaluation of an environmental remodeling program on a psychiatric geriatric ward. Journal of Social Psychology, 123 (1), 101 113.
12. Streim, J.E., Oslin, D., Katz, I.R., & Parmelee, P.A. (1997). Lessons from geriatric psychiatry in the long term care setting. Psychiatric Quarterly, 68 (3), 281-307.
13. Shrivastava, R., Kumar, S., & Jacobson, R.R. (1999). Psychiatric units in district general hospitals: Design issues. International Medical Journal, 6 (2), 119-124.
14. Klaassen, P. (1990). Increased importance placed on resident-centered design. Provider, 16 (10), 43-44.
15. Birren, F. (1989). Color psychology and color therapy: A factual study of the influence of color on human life. New York: Citadel Press.
16. Kwallek, N., Lewis, C.M., Sales, C., and Woodson, H. (1997). Impact of three interior color schemes on worker mood and performance relative to individual environmental sensitivity. Color Research and Application, 22 (2), 121-132.
17. Stone, N.J., & English, A.J. (1998). Task type, posters and workspace color on mood, satisfaction, and performance. Journal of Environmental Psychology, 18 (2), 175-85.
18. ibid.
19. Hiatt, L.G. (1978, November-December). Architecture for the aged: Design for living. Inland Architect, 6-18.
20. Gabb, B.S., Speicher, K., & Lodl, K. (1992). Environmental design for individuals with schizophrenia: An assessment tool. Journal of Applied Rehabilitation Counseling, 23 (2), 35-40.
21. Nursing Homes (1993). Looking good: What designs work best for residents. Nursing Homes, 42 (8), 18-23.
22. Cooper, B.A., Gowland, C., & McIntosh, J. (1986). The use of color in the environment of the elderly to enhance function. Clinical Geriatric Medicine, 2 (1), 151-63.
23. Hiatt, L.G. (1987). Environmental design and mentally impaired older people. In H.J. Altman (Ed.), Alzheimer's disease: Problems, prospects, and perspectives. New York: Plenum.
24. Klaassen, P. (1990). Increased importance placed on resident-centered design. Provider, 16 (10), 43-44.
25. Hiatt, L.G. (1978, November-December). Architecture for the aged: Design for living. Inland Architect, 6-18.
26. Verderber, S., Reuman, D. (1987). Windows, views, and health status in hospital therapeutic environments. Journal of Architectural and Planning Research, 4 (2), 120-133.
27. Kim, I.K. (1998). Subjective responses to daylight, sunlight, and view in college classrooms with windows. Disseration Abstracts International, 58 (7-A): 2425.
28. O'Connor, B.P., Davidson, H., & Gifford, R. (1991). Canadian Journal on Ageing, 10 (3), 216-223.
29. Talbot, J.F., & Kaplan, R. (1991). Benefits of nearby nature for elderly apartment residents. International Journal of Aging and Human Development, 33 (2), 119-130.
30. Stone, N.J., & Irvine, J.M. (1994). Direct or indirect window access, task type, and performance. Journal of Environmental Psychology, 14 (1), 57-63.
31. Dickinson, J.I., McLain, K.J., & Marshall, B.A. (1995). The effects of visual barriers on exiting behavior in a dementia care unit. Gerontologist, 35 (1), 127-130.
32. Brawley, E.C. (2001). Environmental design for Alzheimer's disease: A quality of life issue. Aging and Mental Health, 5 (Suppl. 1), S79-S83.
33. Lovering, M.J. (1990). Alzheimer's disease and outdoor space: Issues in environmental design. American Journal of Alzheimer's Care and Related Disorders and Research, 5 (3), 33-40.
34. Homme, D.R. (2000). Chairs in the context of life experience: An exploratory study. Dissertation Abstracts International, 61 (5-A):1660.
35. Evans, G.W., Lepore, S.J., & Schroeder, A. (1996). The role of interior design elements in human responses to crowding. Journal of Personality and Social Psychology, 70 (1), 41-46.
36. Stolpher, J.H. (1979). Environmental design consideration for long term care facilities. Long Term Care and Health Services Administration Quarterly, 3 (1), 15-23.
37. see Garling, T., & Golledge, R. (Eds.). (1993). Behavior and environment: Psychological and geographical approaches. Amsterdam: North Holland.
38. Nursing Homes (1993). Looking good: What designs work best for residents. Nursing Homes, 42 (8), 18-23.
39. Harvey, M.L., Loomis, R.J., Bell, P.A., & Marino, M. (1998). Environment and Behaviour, 30 (5), 601-627.
40. Hiatt, L.G. (1987). Environmental design and mentally impaired older people. In H.J. Altman (Ed.), Alzheimer's disease: Problems, prospects, and perspectives. New York: Plenum.
41. Ritterfeld, U., & Cupchik, G.C. (1996). Perceptions of interior spaces. Journal of Environmental Psychology, 16 (4), 349-360.
42. Carey, B. (1991). On the edge: Architecture for Alzheimer's. In Health, 5 (2), 18-19.
43. Zgola, J. (1990). Alzheimer's disease and the home: Issues in environmental design. American Journal of Alzheimer's Care and Related Disorders and Research, 5 (3), 15-22.
44. Sime, J.D. (1986). Creating places or designing spaces? Journal of Environmental Psychology, 6 (1), 49-63.
45. Gelwicks, L. (1974). Needs, environmental design, and health care of the aged. In E. Seymour (Ed.), Psychosocial needs of the aged: a health care perspective (Revised Edition). Los Angeles: University of Southern California Press.
46. Moyne, J., Domingos, K., Pittman, R., Beal, L., & Williams, C. (1997). When environmental re-design creates autonomy hindrance: Learning from the investigation of local detail in the study of institutional relocation. Clinical Gerontologist, 18 (1), 15-30.