schizophrenia: programming needs for humanized environments€¦ · schizophrenia is diagnosed by...

Schizophrenia: Programming Needs for Humanized Environments

1


Andrea R. Moreno

Florida International University – Interior Architecture


2

Table of Contents

I. Introduction 5-8

Purpose of Literature Review Significance of Literature Review

II. Emotional and Physiological needs of Young Adults with Schizophrenia 8-9

Psychiatric Needs of Young Adults with Schizophrenia General Needs of Young Adults with Schizophrenia Long Terms Needs of Living for Young Adults with Schizophrenia

III. Learning Needs for People with Schizophrenia 9-10

Learning Methodologies for People with Cognitive Illnesses

IV. Job Training and Job Placing Needs of People with Schizophrenia 10-11

Job Training and Placement Programs for People with Schizophrenia.

V. Counseling and Support Needs for Patients with Schizophrenia 10-11 Vocational Programs

VI. Counseling and Support Needs for Caregiver for People with Schizophrenia 11-12

Caregivers Assisted Counseling Needs

VII. Theories and Methodologies Applied to Schizophrenia 12-13

Linking of Methodologies

VIII. Schizophrenia and the Built Environment 13-16

Design Guidelines for People with Mental Illnesses

IX. Conclusion 16

X. References 17-19

XI. Appendix – A 20-37


3

“If we plant a seed in a desert and it fails to grow, do we ask, "What is wrong with the seed?" No.

The real conspiracy lies in this: to look at the environment around the seed and to ask, "What must

change in this environment such that the seed can grow?" The real conspiracy that we are participating in

here today is to stop saying what's wrong with psychiatric survivors and to start asking: "How do we

create hope filled, humanized environments and relationships in which people can grow?"

- Patricia E. Deegan, Ph.D.


4

Introduction

One of every one hundred people is diagnosed with Schizophrenia. Schizophrenia is a mental

illness characterized by the evidence of delusions, hallucinations, thought disorder and cognitive deficits

(Meyer & MacCabe, 2012). During adolescent years, humans develop working memory, which help fill-in

facts or parts of regular activities in life (Warner, 2000). Patients with Schizophrenia do not develop the

same ability therefore experiencing a deficit in their brain function (Warner, 2000). As a result,

Schizophrenia is usually diagnosed between the ages of 14 and 30 (Meyer & MacCabe, 2012).

Schizophrenia is diagnosed by careful, and analytical observations of symptoms. According to the

DSM-IV criteria for Schizophrenia, two or more of the following symptoms must be present for a

prolonged period of time. Positive symptoms include Delusions, Hallucinations, Disorganized speech,

Grossly disorganized or Catatonic behavior; or Negative symptoms such as Affective Flattening, Speech,

or Motivation (Tandon, 2013). Schizophrenia is a mental illness and disorder of cognitive nature; thus

characterized by a broken thought process and a shift within the bounds of responsiveness (Colman,

2008). People with Schizophrenia suffer of reoccurring episodes. Episodes are defined by specified

duration of time in which the patient has developed acute symptoms that meet the symptomatic criteria

(Tandon, 2013).

Purpose of Literature Review

The intent of this literature review is to understand Schizophrenia and apply the acquired

knowledge, to better the built environment and operations structure of rehabilitation centers and programs

that can promote the wellbeing and, enhance the quality of life for young adults suffering from

Schizophrenia. Enclosed are the analyzed results of a variety of qualitative and quantitative research

studies. This review will explore the environmental and psychological factors within other phenomena

that influence young adults suffering from this mental illness. The research aims to provide an outline

identifying key components which will evaluate treatment options, housing and long term assisted living,

learning and job placement modules, counseling and support groups for caregiver, and implementation of


5

theoretical approaches in hopes of exploring the possibilities that a specialized rehabilitation center will

offer young adults with Schizophrenia.

Significance of Literature Review

As a result of the strenuous nature of treatment for this condition and the absence of research, young

adults suffering from Schizophrenia are usually treated in general rehabilitation centers, psychiatric wards

within hospitals, or psychiatric institutions. Patients suffering from Schizophrenia are in dire need of a

specialized center that will cater to their unique demands. People with Schizophrenia experience recovery

in a different way as it does not occur in a periodical phase, but rather a life long learning process in

which they will conquer and understand how to live life and experience the world in a new way (Deegan,

1196).

Emotional and Physiological Needs of Young Adults with Schizophrenia

Psychiatric Needs of Young Adults with Schizophrenia

Schizophrenia is a debilitating mental illness that usually manifests itself at the early stages of

adulthood (Meyer & MacCabe, 2012). Schizophrenia patients are affected with severe cognitive

impairment. It is categorized as a syndrome and distinguished by psychosis (Insel, 2010). Psychosis is

defined by the presence of delusions, hallucinations, disorganized speech, disorganized or catatonic

behavior. Psychosis can also be defined as a disconnect with reality. Young adults with Schizophrenia

repeatedly experience psychotic episodes. It is important to understand that treatment for Schizophrenia

has not yet been determined, but rather there are a variety of options that minimize the effects of the

symptoms (Richards, 2000). Schizophrenic patients need a combination of Pharmacological medication,

Psychiatric care, and Psychological support (Pilling, 2012). Pharmacological medication deals with the

targeting of dopamine receptors; which is the main treatment for Schizophrenic conditions using Anti-

psychotic medications. Dopamine receptors are linked to the functions of motivation, cognition, memory,

learning and control (Kane, 1997). The medication afforded to schizophrenic patients intends to reduce


6

positive and negative symptoms and improve functional impairment (Meyer & MacCabe, 2012). There are

two main anti-psychotic drugs; first generation anti-psychotic drugs have side effects causing motion and

movements impairments, while second generation anti-psychotic drugs are generally associated with

obesity and metabolic dysfunction (Meyer & MacCabe, 2012).

Psychiatric care for people with Schizophrenia includes the use of targeted cognitive behavioral

therapy also referred as (CBT). This treatment is said to improve the learning, motivation, and emotional

needs of people with Schizophrenia as wells as lessening the burden of psychotic episodes. CBT

treatments have shown positive results in lowering the risk of relapsing and experiencing episodes.

Treatment options lessen the burden and adherence to medication and improve the overall living

experience of patients (Meyer & MacCabe, 2012). Psychological support includes the regular visit to

community mental health teams and support systems.

General Needs of Young Adults with Schizophrenia

Given the acute difficulty that young adults with Schizophrenia endure, it is important that living

needs are assessed. Some suggestions include Community based support programs, Crises assessment

teams, day hospitals, or rehabilitation centers (Meyer & MacCabe, 2012). NICE Guidelines of 2009

acknowledged that Schizophrenia syndrome must be treated with multi-disciplinary approaches such as

cognitive behavioral therapy, family or caregiver therapy, support groups and, art and vocational therapy.

NICE Guidelines suggest that patients should be treated in a non-judgmental manner to emphasize and

promote recovery (Meyer & MacCabe, 2012). Due to the fact that schizophrenic young adults suffer from

auditory hallucinations, delusions and uncontrollable feeling of being controlled by a source outside of

their own will (Warner, 2000), people with Schizophrenia are in dire need of receiving assisted living

programs that will promote healthy environments, and reduce the stressful situations that may lead to the

triggering of episodes and psychotic relapsing.

Long Terms Needs of Living for Young Adults with Schizophrenia


7

“Failure of focus on decent and stable housing means that as many as one third of inpatients remain

in psychiatric hospitals unnecessarily” (Carling, 1990, p.969). It has been proven historically that mental

health patients are in desperate need for specialized residential housing (Carling, 1990). There is an

alarming call for community integration programs that will allow people with severe mental illnesses such

as Schizophrenia to live with the necessary care and become productive individuals within society. Long

term housing opportunities can adopt user-running programs and self help programs where individuals

can obtain jobs as well as day-to-day tasks which would contribute to the running of the housing complex

or rehabilitation center (Carling, 1990). Evidence has shown that providing schizophrenic people with

housing opportunities, motivates the patient to become active individuals and form part of an integrated

community; this in turn will result in a higher retention within the housing complex. Housing complexes

must provide a sense of belonging and allow for social relationships to emerge. Schizophrenic young

adults should be provided with places that they may call their own. Individual rooms and furnishings

within facilities can promote opportunities to regain structure and self worth (Browne & Courtney, 2005).

In an interview conducted for the study: Housing, social support and people with Schizophrenia: A

grounded theory study comparing boarding houses and private homes. An anonymous participant noted:

“At times, however, being alone made thing worse: and if there’s somebody to talk about those ideas

(paranoid ideas) with, I find it much easier, but alone I tend to get lonely and get wound up in the ideas

and it tends to take over.” (Browne & Courtney, 2005, p. 321). This substantial note can project that

community based housing where patients are allowed to have their own space, participate actively within

a community, and have positive social relationships will greatly benefit and improve their living situations

(Browne & Courtney, 2005). Failure to provide patients with housing and community based rehabilitation

programs has proven to have a substantially negative impact, conventionally resulting in patients winding

up in prisons for minor crimes, or becoming homeless (Warner, 2000). It is shown that the antiquated

restraint of people with Schizophrenia in mental heath institutions and the seclusion within these

institutions quite often lead to patients re-living traumatic events (Steinert, Schmid & Gebhardt, 2007).

Rehabilitation programs and housing arrangements should aim to provide people with the support needed

to have “normal settings” and “normal activities” within society (Carling, 1990).


8

Characteristics of housing arrangements and programs for people with Schizophrenia should

promote a sense of belonging (Browne & Courtney, 2005). Housing programming should incorporate

housework and related activities that contribute to the wellbeing of the individuals. Young adults with

Schizophrenia should be exposed to having positive relationships with other young adults suffering from it

as well. Sharing ideas provides patients with support and alleviates schizophrenic anxiety, stress, and

paranoia (Browne & Courtney, 2005).

Learning Needs of People with Schizophrenia

Learning Methodologies for People with Cognitive Illnesses

Learning for people with Schizophrenia is a much more difficult and intensive task than for other

people, as Schizophrenia is characterized by having a severe negative effect on cognitive abilities. This

mental illness is also characterized by a lack of “working memory” therefore fragmenting the thought

process and inhibiting people from filling in the “blanks”(Warner, 2000). Cognition refers to a set of mental

functions that include: attention, memory, learning, reasoning, problem solving, and decision-making

(Oxford). Cognitive behavioral therapy also referred to as (CBT) is one of the most important tools

towards improving the stability of mental health of people with Schizophrenia (Morrison, 2009). CBT is

known to target individualized symptoms of Schizophrenia and provide patients with the adequate relief

for their worries, or feelings of despair (Morrison, 2009).

Given the importance of rehabilitating cognitive behaviors in people with Schizophrenia, approaches

such as cognition enhancing and restorative training are imperative to the improvement of any training or

day to day functioning (Leshner, Tom & Kern, 2012). There are two main approaches to training and

learning for people with Schizophrenia. The first approach attempts to correct the cognitive behavior

using a technique referred to as restorative, which endeavors to improve neurocognitive function (Kern,

Robert, Liberman, Kopelowicz, Green & Mintz, 2002) and is characterized by performing repetitive

exercises where the behavior is absent. Such exercises include computer added drills and task repetition

drills (Leshner, Tom & Kern, 2012). The second technique referred to as compensatory approach, uses

an adaptation or mutation of environment where the absent cognitive behavior is replaced. For example,


9

if there is a day-to-day task that one person must perform, this must be substituted or aided with the use

of calendars, notes and remainders (Leshner, Tom & Kern, 2012). Lack of research for learning programs

has hindered the further development of this section; a majority of research has heavily been focused on

technical training for job placement.

Job Training and Job Placing Needs for People with Schizophrenia

Job Training and Placement Programs for People with Schizophrenia

Supported Job training programs can provide necessary skill training to meet the high demands

within the work force in today’s world (Waghorm, Loyd & Tsag, 2013). Successful approaches to learning

have been widely adopted in the job-training sector. People with Schizophrenia and severe mental

illnesses have a number of available training methods that have produced high success rates such as the

Place-then-Train method. This entails finding a job and then participating in the cognitive training to

adapt to that particular job. The unique feature of this program is that employers are also provided with

tools and assistance when employee people with schizophrenia. (Waghorm, Loyd & Tsag, 2013). In a

study conducted, 60% of people were successful at maintaining a job after completing cognitive therapy

(Waghorm, Loyd & Tsag, 2013).

Errorless Learning is an approach widely used for providing people with Schizophrenia the necessary

skills to join the workforce. Errorless Learning is a compensatory method of training in which people with

Schizophrenia are trained to perform an entry-level jobs by using repetitive practice techniques where

only the implicit memory is targeted (Kern, Robert, Liberman, Kopelowicz, Green & Mintz, 2002). In a

study conducted to compare Errorless Learning approach to a Trial-and-Error learning method, concluded

it that using Errorless Learning methods had better and more positive results than those of Trial-and-Error

learning methods (Kern, Robert, Liberman, Kopelowicz, Green & Mintz, 2002).

Contrasting programs for people with severe mental illness and cognitive disorders are also

available. The Thinking Skills for Work Program was specially designed to provide job training and

support for patients with severe mental illness (McGurk, Mueser, & Pascaris, 2005). The program

consists of four essential steps, Assessment, Computer Cognitive Training, Job Search Planning and Job


10

Support Consultation. These four steps are designed to aid people with mental illnesses to find jobs and

overcome cognitive impairment in order to comply with society’s standards. Additionally to the job

placement benefits of the programs, the cognitive training and being able to hold a job proved beneficial

to depression symptoms within schizophrenic patients (McGurk, Mueser, & Pascaris, 2005). IPS also

known as Individual Placement and Support, has proven to be one of the must sought after programs and

has rapidly gain acceptance with in the schizophrenic community (Bond, Drake, Mueser & Becker, 1997).

This method implies that individuals with mental illnesses are offered support even after finding a job,

therefore providing a more secure platform of employment including vocational skill training and job

support groups (Bond, Drake, Mueser & Becker, 1997).

Counseling and Support Needs for Patients with Schizophrenia

Vocational Programs

Programs that provided individualized, personalized, and flexible options have shown a higher

success rate within the metal health community (Carling, 1990). According to the NICE Standards, people

with Schizophrenia should consider art therapies, which have proven to lessen the severity of negative

symptoms (NICE, 2009, p. 18). Art therapy can positively influence the lives of young adults with

Schizophrenia by enabling them to experience themselves in a different way, finding ways to relate to

others, organizing ideas into an aesthetic composition, as well as coping with feelings and emotions that

can be expressed through art (NICE, 2009, p.20). In addition to necessary medication and psychiatric

care, recent preliminary studies show the successful outcome of new implementations towards the

counseling and support programs provided to people with Schizophrenia. Vocational rehabilitation has

resulted in remarkable improvements within the cognitive functions of patients suffering from

Schizophrenia (Bio & Gattaz, 2010).

CPA the Care Program Approach is designed to deliver schizophrenic patients with rehabilitation

services by using case management method, this includes the assistance of living accommodations

education and community based therapy. Community based services also include family therapy which


11

targets the education of caregivers and immediate family members in management and understanding of

schizophrenic behaviors (Meyer & MacCabe, 2012).

Supplementary to Vocational Programs, the addition of exercise therapy in a regular basis provides a

wide rage of benefits for people with schizophrenia. Exercise therapy provides optimistic benefits to the

effects of negative symptoms experienced in Schizophrenia (Gorczynski & Faulkner, 2011).

Schizophrenia has devastating effects in the physical wellbeing and is linked to obesity and negative co-

morbid effect, caused by cognitive impermanent and side effects of many anti-psychotic drugs. Exercise

has great physical and wellbeing benefits for patients and provides a platform of routine inducing positive

behavior (Gorczynski & Faulkner, 2011).

Counseling and Support Needs for Caregiver for People with Schizophrenia

Caregivers Assisted Counseling Needs

“Around 25% of caregivers of schizophrenic patients, either living with or living apart of the

patients, met General Health Questionnaire criterion for having a mental disorder. Caregivers of the

patients with psychiatric illnesses such as Schizophrenia have significant high level of depression.” (El-

Tantawy1, Raya & and Zaki, 2010). Schizophrenia is a very demanding illness given the cognitive

impartment caused by it. Patients with Schizophrenia are always in need of an assigned caregiver.

Caregivers spend numerous hours of their daily lives providing care. The selflessness and devotion of

caregivers is unlikely compensated, therefore caregivers usually experience symptoms of depression DD

(El-Tantawy1, Raya & and Zaki, 2010). Depression among caregivers is also highly correlated to the

amount of time caregivers spend with the patients (El-Tantawy1, Raya & and Zaki, 2010). Because

caregivers are usually occupied with the task of helping people with Schizophrenia, most affected aspects

of caregivers’ lives are centered around holidays, where caregivers spend most of their time with the

patients’ families rather than their own (Wlnefield & Harvey, 1994, El-Tantawy1, Raya & and Zaki, 2010).

Caregivers or family members are often subject to the burden of living through “episodes.” These stress

filled moments within the Schizophrenia illness are usually a result of heightened stress; thus caregivers

often need the assistance of doctors, staff, or counselors (Wlnefield & Harvey, 1994). Lessening the


12

burden of living through these strenuous moments can most likely alleviate a caregiver’s responsibility

and contribute to their wellbeing. Community based programs should provide specific counseling

programs as well as support groups that target caregivers, in hopes that this programs will provide

caregivers with the necessary tools to focus on positive experiences associated with their role (Wlnefield

& Harvey, 1994, El-Tantawy1, Raya & and Zaki, 2010).

Schizophrenia is a debilitating syndrome, but behind the burden of this troublesome illness there

still remains a person. Caregivers reported that at times living with the patient provided an opportunity to

create a complex day-to-day relationship in which they could enjoy each other’s company (Wlnefield &

Harvey, 1994). Schizophrenia is not an illness suffered alone. Depression among caregivers of people

with Schizophrenia is predominant. Although the burden of Schizophrenia is high on the patient and the

caregiver, involvement of caregivers and family members in the treatment of Schizophrenia has proven to

have high positive effects on the patient and better results in treatment (Warner, 2000).

Theories and Methodologies applied to Schizophrenia.

Linking of Methodologies

Schizophrenia patients suffer from severe cognitive impairment such as attention deficits,

learning impartments, stress and depression (Meyer & MacCabe, 2012; Warner, 2000; Tandon, 2013).

Given that there are known theories that can help alleviate these symptoms; environment and program

design for people with Schizophrenia should apply this knowledge. ART, Attention Restoration Theory,

developed by Kaplan has shown positive effects and significant improvements when applied. ART theory

states that interacting and experiencing environments dense in incitements bring forth involuntary

attention, allowing the intended attention to rejuvenate (Berman, Jonides & Kaplan, 2008). Experiencing

nature has long been proven to improve memory and attention (Kaplan, 1995), as this interaction with

nature can greatly improve cognitive impairment and lighten stress levels. The results of a study

performed by Berman, Jonides and Kaplan in the published literature “The Cognitive Benefits of

Interacting With Nature, 2008” indicate that taking into account the beneficial effects of nature in the

restoration and improvement of cognitive functioning deserve serious consideration to understand its


13

benefits when conducting cognitive training. Nature is a natural stress reliever; it has long been proven to

provide peace and serenity. People reported visiting natural setting have reported lower stress levels

(Stigsdotter, Ekholm, Schipperijin, Toftager, Kamper & Randrup, 2010). As professionals that greatly

influence the layout and structure of living spaces of communities, it is imperative to become aware of the

specific needs of this group of people. Creating quieter spaces filled with greenery, would not only

improve the mental health of Schizophrenics, but of society as a whole.

Providing patients with Schizophrenia interaction with natural environments can contribute to

relieve the burden of cognitive impairments. Natural environments are not limited to only providing

cognitive impairment benefits, they also serve as canvases to a wide variety of positive behaviors. Natural

environments are conductive of increased physical activities, and relaxation exercises. These activities

have been proven to benefit mental health, decrease depression symptoms, and enhance social skills

and interaction (Bowler, Buyung-Ali, Knight & Pullin, 2010). Physical activities such as cardiovascular

exercises and relaxation practices, like yoga, have been admirably beneficial to people suffering from

Schizophrenia. Evidence shows that the symptoms of anxiety and stress substantially decrease after the

practice of these activities (Vancampfort, Hert, Knapen, Wampers, Demunter, Deckx, Maurissen &Probst,

2011). In addition to reducing stress and anxiety, the permanent enrollment to yoga therapy has anti-

psychotic benefits and conduces to an improvement of socio-occupational functioning, as well as a relief

of positive and negative symptoms of schizophrenia (Behere, Arasappa, Jagannathan, Varambally,

Venkatasubramanian, Thirthalli, Subbakrishna, Nagendra & Gangadhar, 2011).

Schizophrenia and the Built Environment

Design Guidelines for People with Mental Illnesses

“The WHO claims that Schizophrenia destroys 24 million lives worldwide, with an exponential

effect on human and financial capital. Because evidence implicates the built environment, architectural

and urban designers may have a role to play in reducing the human costs wrought by the illness”

(Golembiewski, 2013). Because we understand that people suffering severe mental illnesses are subject

to the environment created for people that do not posses these same illnesses; it is important to assess

and recognize that environments should be created to promote the wellbeing and successful rehabilitation


14

of patients with Schizophrenia. Schizophrenic patients have cognitive impairments that greatly fragment

their daily lives. Providing affordances within the design environment can positively affect the routine of

their day-to-day lives.

Evidence shows that chronic noise exposure has been associated with poor mental health (Clark,

Myron, Stansfeld & Candy, 2007). Facilities designed for people with Schizophrenia should provide

acoustical privacy to create a quiet oasis. These spaces should also have access to greenery, the

outdoors and nature, which have shown to positively affect mental health, and likewise provide brain

rejuvenation instances (Clark, Myron, Stansfeld & Candy, 2007; Berman, Jonides & Kaplan, 2008).

Centers for young adults with Schizophrenia should have access to all conditions stated above, in an

effort to provide a positive environment for rehabilitation and wellness.

Schizophrenia is characterized by an acute debilitation to the cognitive brain functions.

Psychological stress and anxiety are two main symptoms experienced by people with Schizophrenia.

Crowding and dense environments have been linked to poor mental health and psychological stress

(Evans, 2003). When providing spaces for people with mental illnesses it is important to not undermined

density ratios. Spatial density has negative effects of mental health (Clark, Myron, Stansfeld & Candy,

2007). The effects of city noise, traffic noise and overall chaos are debilitating to people with

Schizophrenia (Clark, Myron, Stansfeld & Candy, 2007). In recent studies such as “The Camberwell Walk

Study”, the effects of urban noise and exposure were tested against people with psychotic symptoms.

This study concluded that dense environments trigger negative symptoms within a few moments of

exposure (Golembiewski, 2013). The correlation between Schizophrenia and urban birth is alarming, it

has been established that there is a superior risk of Schizophrenia within people born in metropolitan

areas (Clark, Myron, Stansfeld & Candy, 2007).

Housing and long term accommodations for people with sever mental illnesses should provide

choice, housing arrangement should not be heavily limited and should provide re-integration to the

community as well as activities where people are allowed to act independently (Carling, 1990).

Psychological needs of people with mental illnesses are extremely demanding, therefore qualities of

housing should suit their needs (Browne & Courtney, 2005). Rehabilitation centers should provide home-

like atmospheres where patients can feel confortable and have privacy; Communal spaces were visitors


15

may interact should also posses these qualities, making it confortable for both the patient and the visitor

(Douglas & Douglas, 2004). Communal spaces ought to allow for a large variety of functions where the

patients can have interaction with the community, these spaces should not be limited to a specific user,

but rather be nodes where patients, practitioners and staff can interact (Curtis, Gesler, Priebe & Francis,

2009). In the study; “New Spaces of Inpatient Care for People with Mental Illnesses: A Complex ‘rebirth’

of the Clinic” it was noted from an interview: “…maybe because the environment is nice, the patients

themselves look better,…they do try to make the environment look tidy-unlike in the old buildings

[where]…it…[didn’t] matter because the environment itself…[was] not really attractive”. Environments and

surroundings are a direct reflection of self-identity, providing an aesthetically enriched environment

promotes wellbeing and self-esteem. Rehabilitation centers should endorse social interaction rather than

enclose and isolate; these spaces should provide dynamic settings where people are free and have

control over their environment (Deegan, 1988). In such environment Socio-Petal seating arrangements

are encouraged to reduce individual isolation (Evans, 2003).

Mental stability has been linked to lighting conditions; rehabilitation centers and spaces for young

adults with Schizophrenia should consider illumination levels. Light has a direct effect on psychological

health and the reduction of depression symptoms, which have been linked to long exposures to daylight

(Evans,2003). In addition to light, sunlight or natural light is a benefactor to overall health and provides

essential nutrients; such as Vitamin D. Spatial elements are furthermore influential in mental health.

Spatial layouts such as long corridors produce feelings of helplessness and are deprived of affordances.

Corridors are also linked to territorial behaviors and hierarchies; these unpleasant spaces are extremely

negative within social behavior and should be avoided (Evans, 2003).

Designing spaces is mainly comprised of providing affordances; these cues and spatial

interactions provide sensory communication between environment and individual. Patients with

schizophrenia do not have the same perception levels than a regular person would have. Given this

information, spaces designed for people with schizophrenia should be carefully analyzed for affordances

within the space that will affect the patient (Golembiewski, 2013). Spaces with strong symbolic density

and over stimulating can contribute to triggering schizophrenic symptoms. Schizophrenia is also

characterized by impairment of attention, overly complicated plans and intertwining circulations can easily


16

puzzle and disengage patients with schizophrenia; this is not to say that paths and circulation should

hinder the sense of adventure, but rather do so conservatively (Golembiewski, 2013).

Conclusion

Informed design is essential to the built environment; this review of literature intends to inform the

Pharmacological, Physiological, and Psychological needs of people with Schizophrenia. Attempting to

better the quality of life and enhance the outcome of new environments. Mental illnesses are

devastatingly ignored, by understanding the struggles and every day influential factors that people

endure; the built environment can better assess the needs of the users. Schizophrenia is a distressing

illness affecting millions of humans worldwide; providing care and attention to its presence can better the

lives of people suffering this illness as well as those who surround them.


17

References

Colman, A. (2008). A dictionary of psychology. In Oxford University Press. Richards, C. F. (1994). Diagnostic and statistical manual of mental disorders. American Psychiatric Association, 18 (2). 253-262 Kane, (1987) Treatment of Schizophrenia. Schizophrenia bulletin Deegan, P. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 2 , 11-19.

Waghorn ,G., Lloyd, C & Tsang, M. (2013). Vocational rehabilitation for people with psychiatric and psychological disorders. In. International Encyclopedia of Rehabilitation, 1-9.

Clark, C., Myron, R., Stansfeld, S. & Candy, B., (2007). A systematic review of the evidence on the effect of the built and physical environment on mental health, Journal of Public Mental Health, 6 (2), 14-27.

Carling, P. J. (1990). Major mental illness, housing, and supports: The promise of community integration. American Psychologist, 45(8), 969-975.

Steinert, T., Bergbauer, G., Schmid, P. & Gebhardt, R. (2007). Seclusion and restraint in patients with schizophrenia: Clinical and biographical correlates. Journal of Nervous & Mental Disease, 195(6), 492-496.

Hartmann, E. (1976,). Schizophrenia: A theory. Psychopharmacology, 49(1), 1-15.

El-Tantawy, A., Raya, Y., & Zaki, A. (2010). Depressive disorders among caregivers of schizophrenic patients in relation to burden of care and perceived stigma. Current Psychiatry, 17(03), 15-25.

Browne, G., & Courtney, M.D. (2005). Housing, social support and people with schizophrenia: A grounded theory study comparing boarding houses and private homes. Issues in Mental Health Nursing, 26(3), 311-326.

Winefield, H., & Harvey, E. (1994). Needs of family caregivers in chronic schizophrenia. Schizophrenia Bulletin, 20(3), 557-566.

Douglas, C. H. & Douglas, M. R. (2004), Patient-friendly hospital environments: Exploring the patients’ perspective. Health Expectations, 7, 61–73.

Warner, R. (2000). In The Environment of Schizophrenia: Innovations in Practice, Policy, and Communications. London, England: Brunner-Routledge.

Kern, R., Liberman, R. P., Kopelowicz, A., Mintz, & Green, M.F. (2002). Applications of errorless learning for improving work performance in persons with schizophrenia. American Journal of Psychiatry.159 (11),1921-1926.


18

McGurk, S., Mueser, K., & Pascaris, A. (2005). Cognitive training and supported employment for persons with severe mental illness: One-year results from a randomized controlled trial. Schizophrenia Bulletin, 31(4), 898–909.

Curtis, S., Gesler, W. G., Priebe, S., & Francis, S. (2009). New spaces of inpatient care for people with mental illness: A complex ‘rebirth’ of the clinic. Journal of Health & Place. 15 (1), 340–348.

Kaplan , S., & Berman, M. (2010). Directed attention as a common resource for executive functioning and self-regulation. Perspectives on Psychological Science, 5 (1), 43-57.

Stigsdotter, A. U. K., Ekholm, O., Schipperijn, J., Toftager, M., Jørgensen, F. K., & Randrup, T. B. (2010). Health promoting outdoor environments: Associations between green space, and health, health- related quality of life and stress based on a Danish national representative survey. Scandinavian Journal of Public Health. 38(4), 411-417.

Ngamini, N., A., Cohen, A., Courteau, J., Lesage , A., Fleury , M., Gregoire , P., Moisan, J., & Vanasse, A. (2013). Does elapsed time between first diagnosis of schizophrenia and migration between health territories vary by place of residence: A survival analysis approach. Health & Place, 20 (0), 66–74.

Emsley, R.A. & Stein, D.J. (2007). Anxiety and schizophrenia, in anxiety disorders, Blackwell Science Ltd. Oxford, UK.

Dijkstra, M. E., Pieterse, A., Pruyn, (2008). Individual differences in reactions towards color in simulated healthcare environments: The role of stimulus screening ability. Journal of Environmental Psychology, 28 (3), 268-277.

Feierman, J. (1982). Nocturnalism: An ethological theory of Schizophrenia. Health & Place, 9 (5). 455-479.

Macpherson, R., Shepherd, G., & Edwards, T. (2004). Supported accommodation for people with severe mental illness: A review. Advances in Psychiatric Treatment , 10, 180-188.

Evans , G. (2003). The built environment and mental health. Journal of Urban Health, 80(4), 536-555.

Mazuch, R., & Stephen, R. (2005). Creating healing environments: Humanistic architecture and therapeutic design. Journal of Public Mental Health, 4(4), 48-52.

Behere, R. V., Arasappa, R., Jagannathan, A., Varambally, S., Venkatasubramanian, G., Thirthalli, J. Subbakrishna, D., Nagendra, H. R. & Gangadhar B. N. (2011). Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatr Scand. 123. 147-153.

Golembiewski, J. (2013). Lost in space:The place of the architectural milieu in the aetiology and treatment of schizophrenia. Facilities. 31(9). 427-448.

Branas, C., Cheney, R. A., MacDonald, J. M., Tam V. W., Jackson, T. D., & Havey, T. R. A (2010) difference-indifferences analysis of health, safety, and greening vacant urban space. American Journal of Epidemiology. 174(11). 1296–1306.


19

Duggan, L., Brylewski, J. (2013)(Antipsychotic medication versus placebo for people with both schizophrenia and learning disability (Review). Cochrane Database of Systematic Reviews. 4.

Durbin, J., Qoering, P., Cochrane, J., Macfarlane, D. & Sheldon, S. (2004) Need-based planning for persons with schizophrenia residing in board-and-care homes. Schizophrenia Bulletin. 30(1). 123-132.

Vauth, R., Corrigan, P., Clauss, M., Dietl, M., Dreher-Rudolph, M., Stieglitz, S. & Vater, R. (2005). Cognitive strategies versus self-management skills as adjunct to vocational rehabilitation. Schizophrenia Bulletin. 31(1). 55-66.

Morrison, A. (2009). Cognitive behavior therapy for people with schizophrenia. Psychiatry Edgemont. 6(12). 32–39

Kaplan, S. & Berman M. (2010). Directed attention as a common resource for executive functioning and Self-regulation. Perspectives on Psychological Science. 5(1). 43-57

Behere, R. V., Arasappa, R., Jagannathan, A., Varambally, S., Venkatasubramanian, G., Thirthalli, J., Subbakrishna, D.K., Nagendra, H. R. & Gangadhar, B. (2011). Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatr Scand 123. 147–153

Kaplan, S. (1995). The restorative benefits of nature: Towards an integrative framework. Journal of Environmental Psychology. 15. 169-182.

20

Appendix A

A. Initial Thesis Project Questions and Purpose

Central Question

How can the built environment benefit the lives of young adults suffering from schizophrenia and their immediate families?

Sub-Questions

1. How can a rehabilitation and wellness center for schizophrenic young adults provide them with a more adequate facility and treatment program that promotes their re-integration into society?

2. How can the interior environment provide comprehensive care and a more positive environment for schizophrenic young adults and their immediate families or caregivers?

3. What design elements and strategies facilitate learning, training, and life skills in a rehabilitative environment?

4. How can the qualities of nature and the (ART) theory be applied to such environments to alleviate stress and mental exhaustion?

5. How do interior design elements such as color, materiality and spatial organization contribute to a calming state and stress free environment that allows the patient to heal and reduce the number of “episodes” that occur?

Purpose Statement

The intent of this literature review is to understand how the built environment of rehabilitation centers for patients with schizophrenia can contribute and enhance the quality of their lives. By analyzing a variety of qualitative and quantitative research, this study will explore the environmental factors and other phenomena that influence young adults suffering with this mental illness.

B. Possible Typology

1. Option Healthcare / Educational Healthcare / educational, by providing a rehabilitation center that will enhance and provide comprehensive care to people with schizophrenia by allowing programming and design elements to contribute to their mental health. This typology provides an opening for a center of health care, psychiatric services, counseling, and learning facilities. Supportive spaces are there to rejuvenate and help with mental health and provide support to the families’ immediate care givers and patients. Inform design that uses ART restoration theories, nutrition, meditation, exercise, vocational training and counseling.

21

Annotative Bibliography

1. How can rehabilitation and wellness center for schizophrenic young adults provide them with a more adequate facility and treatment program that promote the re-integration into society?

1-1. Annotation:

Deegan, P. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 2 , 11-19.

Patricia E Deegan PhD, a schizophrenic, holds a degree in clinical phycology. She is an active member of the L’Arche Community. Member of the IN-POWER, Director of the Northeast Independent Living Center. Founder and creator of Common Ground, a web application. Recognized by the Agency for Healthcare Research and Quality as a practice innovator. She is an Adjunct Professor at Dartmouth College School of Medicine and at Boston University, Sargent College of Health and Rehabilitation Sciences. This article was published in the Psychosocial Rehabilitation Journal, under the joint sponsorship of the International Association of Psychosocial Rehabilitation Services (IAPSRS) and Boston University's Sargent College of Allied Health Professions, Department of Rehabilitation Counseling. This professional peer reviewed publication aimed to target an audience of psychiatric rehabilitation practitioners and researchers.

The article gives a “perspective point of view” that aims to describe the road to recovery for people with disabilities, as well as to explain how the rehabilitation centers fail under their current set programs. The article aims to provide a pathway to find new ways in how rehabilitation programs can be set up to be more beneficial for people going through such experiences.

Findings:

This paper aims to educate the public in the long and difficult process that recovery is and in doing so we find that recovery programs must change and the rigid walls and programs in today’s world need to change and adapt to those with disabilities.

Quotations:

1. “It is important to understand that persons with a disability do not “get rehabilitated” in the sense that cars “get” tuned up or television “get repaired” People with disabilities are not passive recipients of rehabilitation services. Rather, they experience themselves as recovering a new sense of self and purpose within and beyond the limits of the disability.”

2. “If rehabilitation programs is to be dynamic settings that promote and nurture the recovery process, then the rigid walls separating the “world of the disabled” and the “world of the normal” must be torn down.”

22

1-2. Annotation:

Waghorn ,G., Lloyd, C & Tsang, M. (2013). Vocational rehabilitation for people with psychiatric and psychological disorders. In. International Encyclopedia of Rehabilitation, 1-9.

Hector W. H. Tsang, Ph.D. is an Associate Professor within the Department of Rehabilitation Sciences in the Hong Kong Polytechnic University. The Article Vocational Rehabilitation for People with Psychiatric and Psychological Disorders was published in the Journal of Nervous and Metal Disease, as well as in the International encyclopedia of Rehabilitation. The Article aims to understand how training and job employment can be adapted to people with mental illness. Tsang proposes that the approach “place then train” is a much better solution to employ on people with mental illnesses. The evidence based approach is characterized by a seven step base program and in this program the main idea is to provide employers with the tools necessary to employ people with metal illnesses as well as to help the individual to adapt to the new surroundings. This approach is geared by understanding what training is needed in an individual base case, rather than by using a general training and then placing the individual in a job. The evidence based rehabilitation program has successfully shown in a study that 60% of people with severe mental illnesses using this approach were able to sustain employment.

Findings:

• Advances in vocational rehabilitation and evidence based research show that using a “Place then Train” approach is more effective in rehabilitation for people with severe mental illnesses. This approach is known in practice and has been adopted by rehabilitation programs.

Quotations:

1. “Supported education is a promising intervention, which can help individuals meet the demands of the labor force.”

2. “People with psychiatric or psychological disorders face many barriers and disincentives when returning to work.”

3. “The evidence now supports the opposite approach (place then train). This approach is characterized by seven principles including rapid commencement of a competitive job in line with the person's explicit preferences. This is now considered the beginning rather than the end point of vocational rehabilitation.”

1-3. Annotation:

Clark, C., Myron, R., Stansfeld, S. & Candy, B., (2007). A systematic review of the evidence on the effect of the built and physical environment on mental health, Journal of Public Mental Health, 6 (2), 14-27.

Charlotte Clark a professor and researcher at the Centre for Psychiatry Queen Mary's School of Medicine and Dentistry, University of London in conjunction with Rowan Myron from the Mental Health Foundation, Stephen Stansfeld, member of the Centre for Psychiatry Queen Mary's School of Medicine and Dentistry, University of London and Bridget Candy from the Department of Mental Health Sciences, Royal Free & University College Medical School. She conducted this review which aims to identify and summarize studies published in several peer-

23

reviewed journals in the years between 1990 and 2005 that looked at the effect of the physical environment on people with severe mental illnesses. The findings of the review indicated that urban birth indicated a higher risk of development in Schizophrenia while rural birth males indicated a higher risk of committing suicide. The gatherings and results of the review aim to help the ELF (Health Environment Law group) in the implications of it with regards to the laws.

Findings:

• Evidence shows that chronic noise exposure can be associated with poorer mental health and can severely affect people with mental illnesses.

• Urban birth poses a higher risk of Schizophrenia.

• Rural males are at a higher risk of suicide.

• Access to green spaces was associated with better mental health.

• Children who are witness or victims of crimes have poor mental health.

• Neighborhood regeneration was associated by 9 studies to promote mental health.

• Rental accommodation and housing were not found to be an implicating factor in mental health.

• Neighborhood disorder and crimes were found to be a negative implication on mental health.

• Household spatial density was found to be a negative implication of mental heath for both adults and children.

Quotations:

1. “This implies that the absence of evidence of environmental effects in some domains does not necessarily mean there are no effects – simply that they have not been studied.”

2. “It was surprising that no peer-reviewed journal papers, examining the longitudinal effects of major developments, such as changes to transport infrastructures and facilities, on mental health were identified.”

1-4. Annotations:

Carling, P. J. (1990). Major mental illness, housing, and supports: The promise of community integration. American Psychologist, 45(8), 969-975.

Paul J. Carling, PhD, is the director of the Center for Community Change at Trinity College of Vermont. She is also a faculty member of the Program in Community Mental Health at Southern New Hampshire University and a Senior Consultant of the Centre for Community Change International. She is the author of the book Return to Community: Building Support Systems for People with Psychiatric Disabilities, published in 1994. Her article aims to understand

24

how housing and rehabilitation services affect people with mental illnesses. In this study and review of published article, it is clearly stated that people with mental illnesses need individualized support to re-enter the community. By providing such support, many can achieve successful lives and avoid homelessness.

Findings:

• Individualized and flexible rehabilitation programs for people with mental illnesses are more successful.

• Rehabilitation programs should aim to provide people with mental illnesses with the support needed to have normal housing and normal jobs within a social network.

Quotations:

1. “All people with long term metal illnesses should be given the option to live in decent, stable, affordable and safe housing in settings that maximizes their integration into community activities and their ability to function independently.”

1-5. Annotations:

Steinert, T., Bergbauer, G., Schmid, P. & Gebhardt, R. (2007). Seclusion and restraint in patients with schizophrenia: Clinical and biographical correlates. Journal of Nervous & Mental Disease, 195(6), 492-496.

Professor Steinert is the head of Department Mental Health Care Research as well as Vice medical director and member of management board Centre for psychiatry Suedwuerttemberg and Principal author for German Psychiatric Association (DGPPN) guideline “aggressive behavior”. This Peer reviewed article was published in the Journal of Nervous and Mental Disease and funded by Department of Psychotherapy, Center for Psychiatry Weissenau, as well as by the German Ministry of Education and Research as project of the competence network Schizophrenia. The article aims to understand the effects of seclusion and restraint in patients with Schizophrenia in an attempt to understand how this can affect the patient. The article hypothesizes that seclusion and restraint are directly related to patients that suffer post traumatic stress disorders and a history of trauma.

Findings:

• Seclusion and Restraint in clinical patients with Schizophrenia may cause patients to re-live and re experience traumatic events.

Quotations:

1. “In the long-term course the occurrence of seclusion or restraint in clinical psychiatry is highly associated with a patient’s history of trauma, and such coercive measures may cause re-experienced trauma.”

1-6. Annotations:

25

Hartmann, E. (1976,). Schizophrenia: A theory. Psychopharmacology, 49(1), 1-15.

2. How can the interior environment provide comprehensive care and a more positive environments for schizophrenic young adults and their immediate families or caregivers?

2-1. Annotations:

El-Tantawy, A., Raya, Y., & Zaki, A. (2010). Depressive disorders among caregivers of schizophrenic patients in relation to burden of care and perceived stigma. Current Psychiatry, 17(03), 15-25.

Ashraf Mohamed Mohamed Ali El-Tantawy, Professor of Psychiatry, Suez Canal University, Ismailia, Egypt. M.B.B.Ch. Medical Doctorate Psychiatry, Scholarship Psychiatry, Texas University, USA. Department of Psychiatry, Faculty of Medicine, Suez Canal University, 2 Departments of Psychiatry Faculty of Medicine, Al- Qassim University and 3Al-Gassim Rehabilitation Center. Current Psychiatry (2010); Volume 17, Issue 03, Pages 15-25.The goal of this study is to understand the role of caregivers and depressive disorders caused by the caretaking of people with Schizophrenia. The audience for this particular study is primarily practitioners and members of physiological medicine. This study covers all areas of a caregiver for people with Schizophrenia and provides a very well described and organized idea on how this situation affects them such as causing depression. This article will help me understand how people that care for schizophrenic patients are affected. The information gathered can be used to provide design guidelines and program guidelines for centers of rehabilitation for people with Schizophrenia, thus providing support for both the patient and its immediate caregivers.

Findings:

• Depression among caregivers for people with Schizophrenia is directly related to how much time they spend providing care and the age of the caregiver. It is also related to the level of Schizophrenia that the patient has.

Quotations:

1. “Mental health services must be directed to caregivers as well as patients of Schizophrenia”

2. “Clinicians should be aware of the high rates of DD in caregivers of people with Schizophrenia. In the era of community mental health, it would help to develop community-specific programs to target caregivers for psychosocial intervention which would teach them to focus on the positive feelings they experience in association with the caregiving role”

3. “Mental health services must be directed to the caregivers as well as the patients of Schizophrenia”

2-2. Annotations:

Browne, G., & Courtney, M.D. (2005). Housing, social support and people with schizophrenia: A grounded theory study comparing boarding houses and private homes. Issues in Mental Health Nursing, 26(3), 311-326.

26

Authors of this paper Graeme Browne and Professor Mary Courtney. Browne Holds a RN (RPN & RGN), ADCHN, BSc, MPhil from the School of Nursing, University of Southern Queensland Toowoomba, Queensland, also Head of School, School of Health and Human Sciences, Southern Cross University, Lismore, New South Wales, Australia, and member of Health and Well-Being Research Cluster. Professor Mary Courtney RN, BAdmin (Acc), MHP, PhD in the School of Nursing, Queensland University of Technology Kelvin Grove, Queensland. The Article was published in the Issues in Mental Health Nursing, a peer-reviewed nursing journal that looks at psychiatric and mental health nursing issues. The study aims to identify the differences between housing, social support and community in relation to the mental health of persons suffering of mental illnesses such as Schizophrenia. The study is qualitative in nature as it uses interviews conducted with people who have Schizophrenia to understand the difference and indicators of social factors and housing and thus how it affects them. The article offers findings in the feelings of belonging and preferences in terms of place and how place affects social interactions.

Findings:

• There are two core-categories and thus conclude that if the qualities of the housing suit the needs of the participant they are more likely to stay in their housing, therefore having the feelings of belonging.

• Sense of belonging therefore must provide both opportunity to meet needs, to promote friendship and sense of community and thus satisfying the basic needs of people and prolonging their stay in the housing.

• Qualities of the housing, a sense of belonging by having a place to call their own. For people in housing space of there own, a chair, a room, or any spatial entity to feel that they can have control of. Cost of housings, affected their sense of belonging and money can be an issue in their quality of life. Activities related to housing, having housework provided ease and contributed to mental health while people living in housing facilities lack these sentiments. Stability is highly regarded and valued in terms of longevity and provided metal health. Atmosphere, was viewed in terms of relationships with those in the house, people living in boarding houses reported more cases of having bad atmospheres in terms of negative relationships.

• In terms of relationships, people around people with Schizophrenia contributed to their mental health. People accepting and understanding people view positive understanding from others as a contribution to mental health. Coming home to someone, sharing and understanding was agreed as a positive contribution to all participants across the charts. Living with others provided support and decreased the anxiety of the paranoid ideas.

Quotations:

1. “You invest yourself into your own place ... you feel you belong and it is yours. Where you run your own life”

2. “It’s very important, one of the most important things is... a home where everyone supports you if you need to be supported, ... so that’s the main thing.”

3. “At times, however, being alone made things worse: “and if there’s somebody to talk about those ideas (paranoid ideas) with, I find it much easier, but alone I tend to get lonely and get wound up in the ideas and it tends to take over.”

27

2-3. Annotations:

Winefield, H., & Harvey, E. (1994). Needs of family caregivers in chronic schizophrenia. Schizophrenia Bulletin, 20(3), 557-566.

Helen Winefield associate Professor in the School of Psychology and Discipline of Psychiatry Faculty of Health Sciences, University of Adelaide. This article was published in the Schizophrenia bulletin which reviews developments and empirically based hypotheses regarding Schizophrenia and supported by Oxford University Press. This article reviews the stress caused to caregivers of people with Schizophrenia by analyzing then taking into account the level of contact they have with the patient and how much time they spend with them. It was done by analyzing how families need support and the changes needed in the mental health services so that communities can come together and access the problems. The sampling in this research study provided important insight on the caregivers for people with severe mental health illnesses.

Findings:

• Sources of help for caregivers when patients experienced episodes were found to be more positive when offered by social workers and nurses while doctors were not so helpful and there was a large amount of complains towards them. It is critical that there is a reliable source of help to such caregivers in at any given moment as well as a continuous care community support outreach program.

• All caregivers found that there was a large need for sources of help especially when experiencing episodes by the patients.

• A large percentage of caregivers agreed that living with the patient provided an opportunity to help each other and to coexist with a more complex relationship where they can enjoy each other’s company.

Quotations:

1. “Caregivers clearly want to be kept up to date on new information about Schizophrenia and its causes and treatment. However, caregiver groups that focus only on knowledge about the illness achieve little in terms of reducing caregiver distress”

2. “Holidays and social and interfamilial relationships were the areas of life most frequently disrupted by the caring task, and objective burden in this sense was greater for caregivers in high rather than medium or low contact with the patient.”

2-4. Annotations:

Douglas, C. H. & Douglas, M. R. (2004), Patient-friendly hospital environments: Exploring the patients’ perspective. Health Expectations, 7, 61–73.

Calbert Douglas from the School of Environment and Life Sciences at the University of Salford in the United Kingdom. Lecturer in Environmental and Health Economics and Course Director for the Environmental Management Degree, School of Environment and Life Sciences, University of Salford, Salford, UK. In conjuction with Mary R. Douglas Professional Development Leader, Salford Royal Hospitals NHS Trust, Salford, UK. Published this article in the Health Expectations an international Journal with public participation for health care. The article

28

provides designers with a better understanding of the needs of patients in a hospital to aid hospital design to better fit the patrons’ needs. The article consists of a review of qualitative interviews with the patients of a hospital to better understand their spatial needs. The interviews were conducted all at the same hospital. The Salford Royal Hospitals NHS Trust, Salford, UK. Although the findings of this study are meant for the Salford Hospital, findings can indicate patient’s needs and can be applicable to other institutions to better access the design of hospitals using evidence based research.

Findings:

• Patients perspective indicates that hospitals must provide a home-like space for them as well as the visitors and this subsequently promotes their well-being.

• Patients also reported that access to external area are important and help their recuperation time.

• Patients agree that there is a need for personal space within hospitals for them and their belongings as well as privacy.

Quotations:

1. “It’s patient-friendly when there’s something to occupy your mind during the day – a room to go and have a sit and a drink.”

2. “Privacy is very important and I don’t feel I get it here. Their needs to be something more than just shutting the curtains around your bed as all the ward can still hear. (Female, 35–44 years)”

3. “There was little recreational facility or diversion activity available. The result of this was that they got fed up and bored.”

2-5. Annotations:

Warner, R. (2000). In The Environment of Schizophrenia: Innovations in Practice, Policy, and Communications. London, England: Brunner-Routledge.

Richard Warner as a leader in Schizophrenia treatment and recovery research and development. Author of the Alternatives to the Hospital for Acute Psychiatric Treatment, and Recovery from Schizophrenia. Warner is recognized by the international mental health care community and also a Professor of psychiatry at the University of Colorado. Warner uses the introduction of his book to explain the state of Schizophrenia, diagnosis and to expose the universal inferences to this extremely difficult illness. It also explains in detail the cause and course of the illness. By utilizing this expert’s explanations of the illness and understanding the condition, designing for people with such a cognitive disorder can be more precise.

Findings:

• The involvement of family members in treatment and rehabilitation of people with Schizophrenia can positively affects the results of treatments.

29

• Positive activities such as work are important to the self-esteem of patients suffering from Schizophrenia.

• Because of the lack of community involvements and rehabilitation, there are cases where people with Schizophrenia are housed in prisons because of minor crimes. Many of these crimes are mainly committed because of the lack of care for people which such condition.

• People suffering from Schizophrenia lack “working memory” therefore they cannot fill in blanks like any regular person and therefore are subject to cognitive issues.

Quotations:

1. “Schizophrenia is a psychosis. That is to say, it is a severe mental disorder in which the person's emotions, thinking, judgment, and grasp of reality are so disturbed that his or her functioning is seriously impaired.”



3-1. Annotations:

Kern, R., Liberman, R. P., Kopelowicz, A., Mintz, & Green, M.F. (2002). Applications of errorless learning for improving work performance in persons with schizophrenia. American Journal of Psychiatry.159 (11),1921-1926.

The Primary author of the article Robert S. Kern, PhD is currently a research psychologist in the Department of Psychiatry and Bio Behavioral Sciences at the David Geffen School of Medicine at UCLA, and holds a joint appointment with the Treatment Unit of the Department of Veteran Affairs VISN 22 Mental Illness Research, Education, and Clinical Center (MIRECC). Secondary author Dr. Liberman is a Professor of Psychiatry and is the director of UCLA Center for Research on Treatment & Rehabilitation of Psychosis. The article is published in the American Journal of Psychiatry a peer-reviewed medical journal. The aim of this article is to correlate and test the errorless learning methods in terms of testing its efficacy for teaching people with Schizophrenia. The study hopes to provide people with Schizophrenia with basic training to be able to hold a job and work in the community. By understanding methods that provide training to people with Schizophrenia, rehabilitation centers can provide more of the support but also adequate training for re-integration into society.

Findings:

• Errorless learning methods show that a group trained with these methods showed higher levels of understanding than those trained with conventional methods.

• Both groups showed significant drop task productivity with time.

30

• Errorless learning proves to be a good tool in training for people with Schizophrenia for task performing jobs but has not yet provided any significant improvement in people with Schizophrenia for long term employment.

Quotations:

1. “Obviously, the more diverse and multifaceted the job, the more difficult and time-consuming it would be to apply errorless learning training procedures”

2. “Even with relatively simple job tasks, errorless learning takes considerably longer than conventional methods of instruction. Studies examining the cost/ benefit ratio of errorless learning are warranted.”

3-2. Annotations:

McGurk, S., Mueser, K., & Pascaris, A. (2005). Cognitive training and supported employment for persons with severe mental illness: One-year results from a randomized controlled trial. Schizophrenia Bulletin, 31(4), 898–909.

Susan R. McGurk and Kim T. Mueser from the New Hampshire–Dartmouth Psychiatric Research Center, Department of Psychiatry, Dartmouth Medical School in conjunction with Alysia Pascaris from the agency New York Work Exchange, Coalition of Voluntary Mental Health Agencies, Inc. Wrote a published article for the Schizophrenia Bulletin which reviews developments and empirically based hypotheses regarding Schizophrenia and supported by Oxford University Press. The article examines cognitive training for people with severe mental illnesses who had experienced job failure. This study aims to improve chances of job success within the community. By providing people with severe mental illness with the cognitive training and helping them to obtain a successful job their lives improved and they experienced self-esteem, less severe symptoms in terms of episodes, and an overall improved sense of recovery. The Thinking Skills for Work Program was tested among a random group and it a received a 91% positive outcome. The Thinking Skills for Work Program contains several components in which participants participate in comprehensive, vocational and cognitive assessment and training, they also receive individualized support and job consultative support.

Findings:

• Patients who participated in the Thinking Skills for Work Program demonstrated significantly greater improvements on the Depression sub- scale of the PANSS.

• Cognitive training itself was found to reduce depression symptoms.

3-3. Annotations:

Bond , G., Drake , R., Mueser, K., & Becker , D. (1997). An update on supported employment for people with severe mental illness. Psychiatric Services, 48 (3), 335-346.

The supported employment update for people with severe mental illnesses was conducted in Department of Psychology, Indiana University-Purdue University, Indianapolis by professor Bond and Drake Mueser, and Ms. Becker affiliates of the New Hampshire-Dartmouth Psychiatric Research Center in Concord, New Hatnsphire. Published in the Psychiatric Services Journal supported by the American Psychiatric Association. The article reviews the effectives and

31

effects on people with severe mental illness in regards to obtaining supportive employment services. The findings are based on the result of several studies in which all suggest a number of benefits to obtaining support employment services. The study suggests that there is more research needed in the long-term results of supported employment services for people with severe mental illnesses.

Findings:

• Non-experimental studies suggest that IPS Individual Placement and Support has a higher employment rate, and centers are adopting this method of help.

• Experimental Studies, Suggested that supported employment programs had a higher success rate than broker employment programs.

3-4. Annotations:

Curtis, S., Gesler, W. G., Priebe, S., & Francis, S. (2009). New spaces of inpatient care for people with mental illness: A complex ‘rebirth’ of the clinic. Journal of Health & Place. 15 (1), 340–348.

An Article written by Sarah Curtis professor at the Durham University in the UK, in conjunction with Professor Gesler of department of geography at the University of North Carolina U.S., Stefan Priebe of the University of London in the unit for social & community psychiatry, and Suzanne Francis from the commission of architecture and the built environment. Published at the Health and Place Journal, interdisciplinary journal for the study of different features of health as well as health care environment for which place and location are of importance. The paper aims to conduct a study on design standards for community base spaces where people with mental illnesses are housed. The study uses an in-patient hospital in London and researches the effects of the people and how they feel within the unit. This study aims to understand how the findings of this study can be applied to the design of new spaces.

Findings:

• Spaces where patients can meet the community and the community can come to them are important for recovery.

• Spaces that are of public nature and can be used in a variety of ways such as by the people with mental illnesses as well as staff or practitioners.

• Spaces must meet a large array of functions where the user meets the outside and can have interaction with the community that they will return to.

Quotations:

1. .“…maybe because the environment is nice, the patients themselves look better,…they do try to make the environment look tidy-unlike in the old buildings [where]…it…[didn’t] matter because the environment itself…[was] not really attractive.”

2. How can the qualities of nature and the (ART) Attention Restoration theory be applied to such environments, to alleviate stress and mental exhaustion?

32

3-5. Annotations:

Behere, R. V., Arasappa, R., Jagannathan, A., Varambally, S., Venkatasubramanian, G., Thirthalli, J. Subbakrishna, D., Nagendra, H. R. & Gangadhar B. N. (2011). Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatr Scand. 123. 147-153.

Behere, Arasappa, Venkatasubramanian, Thirthall, Gangadhar from the department of psychiatry in the University, Bangalore, India. In collaboration with Subbakrishna, from Biostatistics, National Institute of Mental Health and Neurosciences, and Nagendra Vivekananda Yoga Anusandhana Samsthana. Conduct an investigation for the B. N. Gangadhar, Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore-560029, India. Investigating the effects of Yoga in Schizophrenic patients.

Findings:

• Yoga therapy is beneficial as an additional therapy method in conjunction to the cognitive approach for therapy.

• Yoga has proven lo lessees the negative effects of anti-psychotic medication and help with stabilizing patients.

• Yoga is beneficial to socio-occupational functioning

4-1. Annotations:

Kaplan , S., & Berman, M. (2010). Directed attention as a common resource for executive functioning and self-regulation. Perspectives on Psychological Science, 5 (1), 43-57.

Professors Kaplan and Berman from the department of psychology at the university of Michigan. Publishing the research in the perspectives and psychological science journal, a journal of the association of physiological science. This research aims to understand by which means can executive functioning and self-regulation be addressed. This regulation theory proposes that self-regulation and functioning requires a level of attention. There are two types of attention, voluntary and involuntary, and by recovering the direct attention we are therefore re-energizing and self regulating. The study proposes that our mental health is aided by using Kaplan attention restoration theory. Attention restoration is also known to help in a wide range of physiological problems.

Findings:

• Attention restoration theory provides a wide range of benefits including help with processing limitations and relief of aggression among other physiological problems.

• Attention restoration theory helps restore our direct or voluntary attention by rejuvenating our brain using natural settings.

• Similar underlying circumstances provide grounds to believe that the attention restoration theory can be applied to other physiological problems.

33

4-2. Annotations:

Stigsdotter, A. U. K., Ekholm, O., Schipperijn, J., Toftager, M., Jørgensen, F. K., & Randrup, T. B. (2010). Health promoting outdoor environments: Associations between green space, and health, health- related quality of life and stress based on a Danish national representative survey. Scandinavian Journal of Public Health. 38(4), 411-417.

This article is a collaboration by several high renowned members of the health and environmental studies. The authors Ulrika K. Stigsdotter Forest & Landscape Denmark, University of Copenhagen, Ola Ekholm, Mette Toftager and Finn Kamper-Jørgensen members of the National Institute of Public Health, University of Southern Denmark, Jasper Schipperijn from the Institute of Sport Science and Clinical Biomechanics, and Thomas B. Randrup from the Forest & Landscape Denmark, University of Copenhagen, Denmark. Published by Scandinavian Journal of Public Health an international peer-reviewed journal publisher of high quality research. The article aims to examine the relations between health and green spaces by using variables such as stress and well-being. The article takes into account the results of a large survey and interviews that qualify the levels of stress and well being in relation to proximity of green spaces. The results show that natural environments are usually used to alleviate symptoms of stress. Because Schizophrenia has a tie to stress levels, this article will aide the research as it positively confirms that there is a great need of natural spaces to help aide and promote the rehabilitation of patients with Schizophrenia.

Findings:

• People living more than 1 km away from a natural space have poorer health and experience higher levels of stress.

• People with lower levels of stress report visiting a natural environment often.

• Green space promotes health and mental well being.

4-3. Annotations:

Berman , M., Jonides , J., & Kaplan , S. (2008). The cognitive benefits of interacting with nature. Psychological Science. 19 (12). 1207-1213.

Marc G. Berman, Stefan Kaplan, and John Jonides from the Department of Psychology, University of Michigan write this article published in the Psychological Science Journal, a peer reviewed journal. The article examines and juxtaposes the cognitive differences cause between natural and urban settings and environments by using the attention restoration theory as a measure of healthy positive natural environments.

4-4. Annotations:

Ngamini, N., A., Cohen, A., Courteau, J., Lesage , A., Fleury , M., Gregoire , P., Moisan, J., & Vanasse, A. (2013). Does elapsed time between first diagnosis of schizophrenia and migration between health territories vary by place of residence: A survival analysis approach. Health & Place, 20 (0), 66–74.

An article from the Health and Place Journal, interdisciplinary journal for the study of different features of health as wells as health care environment for which place and location are

34

of importance. Written by Ngamini Ngui A, Cohen AA, Courteau J, Lesage A, Fleury MJ, Grégoire JP, Moisan J, and Vanasse A. from the Groupe PRIMUS, Centre de recherche clinique Étienne-Le Bel, Université de Sherbrooke. The study attempted to understand migratory patterns among patients with Schizophrenia. It analyzed the patterns from when the patient is diagnosed with Schizophrenia and time frame at which the patient looks to relocate, as well as what area does the patient look to relocate to.

Findings:

• People with Schizophrenia living in urban areas are more likely to migrate than patients living in rural areas.

• Patients of Schizophrenia living in urban areas are more likely to migrate to other urban areas.

• Patients in rural areas are more likely to migrate to urban areas.

Quotations:

1. “In fact, a diagnosis of Schizophrenia is generally followed by loss of job, disintegration of the social network, loss of self-esteem and perception of social stigmatization. Because patients cannot maintain the same standard of living as before the diagnosis, there is a tendency to move into more socially deprived areas”

2. Migration of patients with Schizophrenia may negatively affect treatment and disrupt continuity of care.

4-5. Annotations:

Emsley, R.A. & Stein, D.J. (2007). Anxiety and schizophrenia, in anxiety disorders, Blackwell Science Ltd. Oxford, UK.

Medical Research Council Unit on Anxiety Disorders, Department of Psychiatry, University of Stellenbosch. This article aims to understand the connection between anxiety and the metal illness of Schizophrenia. In this article, the author explains how there is evidence to the linking of both disorders.

4-6. Annotations:

Dijkstra, M. E., Pieterse, A., Pruyn, (2008). Individual differences in reactions towards color in simulated healthcare environments: The role of stimulus screening ability. Journal of Environmental Psychology, 28 (3), 268-277.

5. What interior design elements color, materiality and spatial organization contribute to a calming state; and stress free environment one that allows the patient to heal, and reduce the times “episodes” occur?

5-1. Annotations:

35

Feierman, J. (1982). Nocturnalism: An ethological theory of Schizophrenia. Health & Place, 9 (5). 455-479.

Doctor Feierman from the Vista Sandia Hospital writes an article for the journal of Health and place in which he identifies the different characteristics and effects of daylight and nighttime within the brain function of a patient with Schizophrenia. In this theory, the author explains how the people suffering from Schizophrenia have an abnormal thought process in which they process information during daylight as if they were in a state of sleep.

5-2. Annotations:

Macpherson, R., Shepherd, G., & Edwards, T. (2004). Supported accommodation for people with severe mental illness: A review. Advances in Psychiatric Treatment , 10, 180-188.

Rob Macpherson consultant in rehabilitation psychiatrist for the NHS Foundation Trust and Head of the School of Psychiatry for the Severn Deanery, in conjunction with Geoff Shepherd professor at the Health Services and Population Research Department at the Institute of Psychiatry, University of London and Tom Edwards a specialist registrar in psychiatry at Wotton Lawn, Gloucester. Write this article for the Journal of Advances in Psychiatric Treatment a journal dedicated in continuing professional development, published by The Royal College of Psychiatrists. The article aims to study and examine the different options available of housing and supported living for people with severe mental illness in the UK. It also describes standard option available of this form and the needs of improvements. They conclude that living accommodations for people with severe mental illnesses are essential and they should provide a sense of community and support.

Findings:

• Housing arrangements should provide care-packages that offer opportunities for patients and allow them to choose options in how to live.

• Care providers and government should continue to work together in creating partnerships that increase and better the standards of living for people with severe mental illnesses.

• Energetic and positive approaches for understanding and helping with the burden that affects residents of assisted living conditions.

Quotations:

1. “In the new, dispersed, multi-agency system of community care, the issues of care quality and staff training are now more complex and also, arguably, more important.”

5-3. Annotations:

Evans , G. (2003). The built environment and mental health. Journal of Urban Health, 80(4), 536-555.

An article supported by the department of Design and Environmental Analysis and Human Development at Cornell University US. In this article published by the journal of Urban Health, the author Dr. Gary W. Evans from the Department of Design and Environmental Analysis and Department of Human Development at the Cornell University provides a detailed view of how the built environment affects the mental health. This article aims to explain the spatial and design

36

elements such as furnishings and spaces, and how this can affect their ability to interact and have social interactions.

Findings:

• High-rise, multiple dwelling units are linked to anxiety and depression; this is also due to the isolation of public spaces and multifunction spaces that allow for social interaction.

• People living in poor-quality housing experience low self esteem.

• Neighborhood quality and economical status are likened to mental health. People that move to better neighborhoods are often positively affected and their mental health is improved.

• In Institutional Settings Sociopetal seating arrangement reduce isolation.

• In psychiatric environments, patient that are allowed their privacy and have their own rooms are shown to have better social interaction than those who are in multi-person room arrangements.

• Small geometric arrangements with a small number of patients and clear floor plans that use landmarks are liked to positive outcomes including a reduction on depression, disorientation, and behavioral disturbances.

• Provision of non-institutional homelike features is liked to improvement in mental health.

• Crowding is linked to physiological stress.

• City noise and traffic noise was also linked to an increase on physiological distress.

• Pollution and toxins have also been linked to mental health.

• Illumination levels are also important to consider since they are linked to psychological health and mental stability. Depression is more rapidly cured when patients are exposed to larger periods of daylight.

• Mental heath is also directly related to the flexibility of space and how people can control their immediate surroundings.

• Spatial layouts such as long corridors tend to produce the feeling of helplessness.

• Tall, large structures, long interior corridors, can produce problems with territorial control.

• Physical proximity and semi-public spaces increases social interaction.

Quotations:

37

1. “However, at this nascent stage of scholarship on the built environment and mental health, the most pressing need is better understanding of the psychosocial and biological processes that underlie the pathways potentially linking the built environment to mental health.

5-4. Annotations:

Morrison, A. (2009). Cognitive behavior therapy for people with schizophrenia. Psychiatry Edgemont. 6(12). 32–39

Anna K. Morrison, MD. Associate professor at the Department of psychiatry in the wright State University Boonshoft School of Medicine, Dayton, Ohio. Published by the Psychiatry (Edgmont) A peer-reviewed journal combining conventional wisdom with state-of-the-art thinking. The article looks at the different behavioral therapies available to people with schizophrenia.

Findings:

• CBT treatments for people with schizophrenia, is a successful cognitive training method.

• CBT Treatments also alleviate and help people with schizophrenia with coping methods.

5-5. Annotations:

Kaplan, S. (1995). The restorative benefits of nature: Towards an integrative framework. Journal of Environmental Psychology. 15. 169-182.

Stephan Kaplan a renowned researcher and professor of Professors of psychology at the University of Michigan, specializes in the research of environmental psychology. His research specializes in understanding the restorative attributes of nature. He published the article for the Journal of Environmental Psychology a peer reviewed journal serving the individual in a large range of disciplines and trades specialized in the relationship between people and their environment.

Findings:

• Stress levels and attention components are both directly interconnected

• Attention and Stress can benefit from restorative experiences.

• The restorative attributes from nature and experiencing nature are beneficial to the attention levels and stress levels.

schizophrenia: programming needs for humanized environments€¦ · schizophrenia is diagnosed by...

Documents