Urgent Matters –Through Space

Master of Interior Architecture Sandberg Instituut

Insight Series #3 Urgent Matters – Through Space

Insight Series #3 Urgent Matters – Through Space

Introduction

Insight Series #3 Urgent Matters – Through Space The role of the interior architect is changing and therefore the education towards this profession should be critical about its own position in society.

The Master of Interior Architecture at the Sandberg Institute trains the students to become capable of producing innovative and unorthodox designs through autonomous research and experimentation. They learn to generate future-proof solutions for the complex spatial design tasks of today.

They are able to present their work and confront, discuss and reflect on it. They are encouraged to fully develop their creativity and other capacities through experimentation, research, presentation and confrontation on ‘social sustainable’ subjects in our society.

Henri Snel Head of Master programme Interior Architecture

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Master of Interior Architecture Sandberg Instituut

Insight Series #3 Urgent Matters – Through Space

Introduction

Master of Interior Architecture Sandberg Instituut

I will list some examples that are representative for the ‘social sustainable’ programme:

Insight Series #3 Urgent Matters – Through Space

Introduction

the arising opportunities to improve the space specifically for this target group.

Apart from investigating these socially relevant projects and the need to follow up on it, a lot of attention has also been paid to the ‘free space – the space of the blind spot mirror’. The space that often leads to new insights, the space between the various occupational disciplines, the so-called ‘inter-architectural space’. In my opinion, this development led to redefining our field of study and has ‘enriched’ the students and therefore the education.

With regard to this, I list a number of special activities:

> ‘Rethinking Sandberg’, through research on education and looking at which opportunities exist in the future, a need has arisen to investigate the proper educational system. > ‘Living in Vacancy’, housing demand is still increasing and the vacancy in offices is high, which may have a meaning for both of them. > ‘Circus Elleboog’, with a strong social youth embedding and a conception in Amsterdam, got a new location.

The Sandberg Institute was asked to shape and develop this into a place with a more regional character. The result was a multidisciplinary cooperation of several Master programmes within the Sandberg Institute. > ‘Who is afraid of Alzheimer’s’, a study of the haptic characteristics of nursing homes and

> ‘The one minutes’, in different projects and excursions the phenomenon of registering exactly 60 seconds of video gave the students new insights in being ‘super precise’. > The project is based on a week long series of interventions, performances and other 2

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Master of Interior Architecture Sandberg Instituut

Insight Series #3 Urgent Matters – Through Space

Introduction

Master of Interior Architecture Sandberg Instituut

activities in the public space of Singapore.

The theme of re-introduction of myth in contemporary Singaporean society. > 48/h internship, processing insight during research at work. The ultimate equivalent of theorizing, but necessary to feed the theory.

This educational model has been leading students to independent Interior Architects. They can execute work for clients and formulate their own tasks. They can work independently or in (international) multidisciplinary teams. They are able to contribute extensively to interdisciplinary projects and have an open attitude towards their environment and involvement with others and society in general.

The designs are grounded in the strong knowledge base students acquire during their studies. Their working method reflects their character, which enables them to grow independently and continuously.

Their relationship to their discipline is independent and critical. They develop a

Insight Series #3 Urgent Matters – Through Space

Introduction

personal approach to complex spatial tasks and by doing so shape their own future. The social relevance of graduation project subjects is typical for this approach. I’m therefore very proud that subjects like the human experience of space, the nomadic existence of living, respectfully dealing with dementia in time and space, the awareness of the invisible world around us and touch as an almost forgotten Architectural phenomenon are negotiable, visible and explored in depth.

Thanks to their independent and personal attitude. I believe that the graduates can grow to become inspirational examples within their profession.

Henri Snel Head of Master programme Interior Architecture

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Insight Series #3 Urgent Matters – Through Space

Contents

Master of Interior Architecture Sandberg Instituut

Insight Series #3 Urgent Matters – Through Space

Contents

Contents

Master of Interior Architecture Sandberg Instituut

INTRODUCTION ................................... 1

> Henri Snel

- Alzheimer’s disease........................ 8 - TRANSIT community......................... 12

Urgent Matters – Through Space

> Tom van Alst

- Space and Surveillance in the age of digital Mobile Media . 50 - Invisibilis Radialis Sensorum / research.................... 89

> Ricky van Broekhoven

The Agency of Touch ................... 104 > Jack S. C. Chen IMAGE SECTION ................................ 206

> Collective visual brainstorm

Call for suffering....................... 234 THESIS............................................... 268

> Wenqian Luo

A Temporary Room and the System of Comfort....... 298

> Chanida Lumthaweepaisal

- The Healing Environment ........... 376 - reconsidered From Alzheimerbus to Lijn#3210 .......... 506

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> Naomi Cheung San

> Special Thanks...................................... 410 > Colophon ........................................... 412 > Reference List ..................................... 414

Alzheimer’s Disease TRANSIT Community

Introduction

Tom van Alst

Alzheimer’s Disease

Alzheimer’s Disease TRANSIT Community

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Charles (patient) and Jane (caretaker), November 2006, Texas

In the future, the decreasing of health care budgets will cause a transformation in Dutch social development. These budget cuts will also have an impact on the care of Alzheimer’s patients. The Alzheimer’s disease, which is a form of dementia, is a mental disease which causes memory impairment and social disorders. As the ageing of society increases in the future, simultaneously, the number of Alzheimer’s patients will increase, since this disease primarily occurs in old age. Nowadays, early stage Alzheimer’s patients live at home but in the regressive phase of the disease they require formal care in a nursing home. Since it will be not financially feasible to expand nursing homes in the future, home care will become the prospective solution. (Interview 1) Alzheimer’s patients experience the future increase of home care as a positive development since they compare institutions, such as nursing homes, with a prison.

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Margaret Nance, December 31 2010, New York

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Introduction

Tom van Alst

Alzheimer’s Disease TRANSIT Community

Home Care

Tom van Alst

The burden of home care

Alzheimer’s Disease TRANSIT Community

Home Care

Tom van Alst

How to unburden home care?

According to an environmental psychologist, who is specialised in Alzheimer’s care, new concepts should be developed to decrease the burden of home care as this stimulates the home care process (Interview 1). She explained that the changing of the daycare department in nursing homes into a temporary place where Alzheimer’s patients can stay three days a week is too difficult.

The temporariness of this place does not provide Alzheimer’s patients a balanced social environment. She suggested developing a non-institutional ‘holiday stay’ which Alzheimer’s patients and informal caretakers can visit once in a few months. One advantage of a holiday is that both Alzheimer’s patients and informal caretakers are temporarily released from the duties of care, signaling a return to their actual familial relationship.

What is generally unknown about home care is the burden of informal caretakers, often relatives or friends of patients, during this process. A recent study written by the research network of the Academic Medical Centre of Amsterdam, describes why home care is a burden for informal caretakers. The study explains that home care is a part of normal life, yet in reality it is the opposite: it takes a lot of personal time from the informal caretaker, who needs to attend to the mental and physical state of the patient (Palmboom & Pals, 2008, p.7). This burden changes the actual (familial) relationship between informal caretaker and patient into a care relation. Informal caretakers experience this loss of the former relationship akin to the grieving process.

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TRANSIT Community

Introduction

Tom van Alst

TRANSIT Community

TRANSIT Community

The guest room

Tom van Alst

The changing function of the guest room The TRANSIT community, in keeping with the model of the Labre community, changes the function of this guest room into a holiday stay for Alzheimer’s patients and their informal caretakers. During the holiday stay, the residents of the community take care of the Alzheimer’s patients so that the burden of care between informal caretaker and Alzheimer’s patient is temporarily released. Furthermore, guests are involved in the life of the TRANSIT community so that they can draw strength from this togetherness. An additional advantage for the residents in the community is that, through the changing function of the guest room, they can practice their part-time job in the community in order to get a stable income.

I have developed a concept called ‘The TRANSIT community’, which is a holiday stay for Alzheimer’s patients and their informal caretakers. The TRANSIT community appropriates the spatial model of the Labre community, located at the Plompetorengracht in the centre of Utrecht. The Labre community consists of thirty residents whose ages range from five to fifty-five years old. Most of them are artists or social workers and, in order to get a stable income, some have a part-time job in the health care sector. Each resident owns a dwelling within the community and simultaneously shares the facilities with other residents. An example of a shared facility is the guest room intended for family and friends of the residents.

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TRANSIT Community

Existing situation

Tom van Alst

TRANSIT Community

Function diagram, existing situation

Existing situation

Quiet garden Communal library

Chapel

Bath room

Room resident

Communication

Bath room

Active garden

Open kitchen

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Tom van Alst

TRANSIT Community

The guest room

Tom van Alst

How to position the guest rooms?

TRANSIT Community

Environmental activity

Tom van Alst

Environmental activity The three types of guest rooms are positioned in the building on the basis of the environmental activity of Alzheimer’s patients. Since zen-demented persons need a quiet environment, wanderers need an active environment and balance seekers need to be in between, the guest rooms will have different positions in the building.

The TRANSIT community offers three types of guest rooms to Alzheimer’s patients and informal caretakers. These types of guest rooms are designed and positioned on the basis of the particular characteristics of three types of Alzheimer’s patients described by Anneke van de Plaats. Van der Plaats classifies three types of patients: the zen-demented person, the balance seeker and the wanderer. A zendemented person is an introvert patient who benefits from a quiet environment. In contrast to a zen-demented person, a wanderer is an extrovert patient who benefits from an active environment. These patients often wander around in the corridors to search for impulses. A balance seeker is a semi-extrovert patient who is often physically disabled.

These patients scream or sing to create impulses, as they are not able to wander around to search for impulses (Plaats, van de, 2008, p.72).

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TRANSIT Community

Activity

Tom van Alst

TRANSIT Community

Activity diagram, existing situation

08:00 AM

This diagram shows the average daily activity in the building, which includes audible and visual impulses, recorded at four different times in a day.

I obtained this data by field observations on diffe- rent weekdays.

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01:00 PM

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Activity

Tom van Alst

TRANSIT Community

Activity

Tom van Alst

04:00 PM

TRANSIT Community

09:00 PM

High activity Average activity Low activity

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Activity

Tom van Alst

TRANSIT Community

Positioning of the guest rooms

Tom van Alst

TRANSIT Community

Positioning of the guest rooms

Positioning of the guest rooms

Wanderer Colored space

Balance seeker Shell

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Zen-demented person Monolith

Tom van Alst

TRANSIT Community

Design of the guest rooms

Tom van Alst

Design of the guest rooms

TRANSIT Community

Design of the guest rooms

Tom van Alst

Design for primary usage The first design criterion is ‘design for primary usage’. An informal caretaker states: ‘Once I am on holiday, I use a holiday stay just for the primary needs as sleeping and showering so that I can spend the rest of the time in the surrounded environment’ (Interview 6).

In TRANSIT community, the guest room functions as the holiday stay and the rest of the community functions as ‘the surrounding environment’. Therefore the guest rooms in the TRANSIT community should provide guests only primary functions. This means that each guest room consists of a bath room and a bed room. The bath room includes a shower, toilet, sink, cupboard; the bed room includes a double bed and a wardrobe. The primary functioning of the guest rooms stimulates guests to involve into the communal life which encourages the socially engaged atmosphere the TRANSIT community is aiming for.

Based on the information from the interviews with informal caretakers and Alzheimer patients, I considered the following criteria for designing the three guest rooms: Design for primary usage, Degree of flexibility, Visual interaction, Color-contrast environment, Distinguishing architectural language.

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TRANSIT Community

Design of the guest rooms

Tom van Alst

Degree of flexibility

TRANSIT Community

Design of the guest rooms

Tom van Alst

Visual interaction The third design criterion is ‘visual interaction’ between the guest room and the surrounding communal spaces to provide guests with visual impulses. One informal caretaker explains that Alzheimer’s patients often like to be voyeurs. This means that the guest rooms should be provided with ‘peek holes’ which stimulates a voyeuristic play between the guest room and the surrounding spaces (Interview 5).

The second design criterion is ‘the degree of flexibility’ in the guest rooms.

Besides the two private spaces, the bed room and the bath room, every guest room consists of semi-public spaces. These semipublic spaces have a flexibility in terms of territory, which means that a semi-public space is both a private territory of the guest room and a public territory of the community.

This degree of flexibility in the guest rooms corresponds to the philosophy of the TRANSIT community: the inclusion of the voice of the guest. Since guests can partly own public spaces, they have a voice in making spatial divisions within the community.

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TRANSIT Community

Design of the guest rooms

Tom van Alst

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TRANSIT Community

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Design of the guest rooms

Tom van Alst

TRANSIT Community

Design of the guest rooms

Tom van Alst

TRANSIT Community

Design of the guest rooms

Tom van Alst

Color-contrast environment The fourth design criterion is that guest rooms have a ‘color-contrast environment’. Alzheimer’s patients cannot distinguish flooring from walls if the color tones are too similar. Therefore I use contrasting bright colors in the design of the space(s).

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TRANSIT Community

Design of the guest rooms

Tom van Alst

Architectural language

TRANSIT Community

Flexible territories This diagram shows how the private territory of each guest room can change.

Each guest room has a distinguishing architectural character. An architectural language is defined as the creation of a spatial character by a certain usage of walls, colors, materials and light. Informal caretakers and Alzheimer’s patients state that they expect the guest rooms to have a bold, provocative spatial character, to not remind them of the spatial character of their home.

Private territory

Communal territory

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Design of the guest rooms

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Tom van Alst

TRANSIT Community

Design of the guest rooms

Tom van Alst

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TRANSIT Community

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Design of the guest rooms

Tom van Alst

TRANSIT Community

Monolith

Tom van Alst

TRANSIT Community

Monolith Zen-demented persons benefit from a quiet environment which means that the architectural language of this guest room has a closed character. Therefore thick walls are used to protect the guests from the distracting visual and audible impulses.

The interior functions, as the bedstead, the wardrobe, the shower, the sink, the bathroom cabinet and the toilet, are carved out from the thick walls. This type of design is also called ‘monolithic design’. When guests use these interior functions, they feel literally embraced by the walls. This embracement offers guests a high sense of safety which is from main importance for zen-demented persons.

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Photo of a walk way in the Monolith

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Monolith

Tom van Alst

TRANSIT Community

Monolith

Tom van Alst

Blue and orange

TRANSIT Community

Monolith

Tom van Alst

Communal library The guest room partly accommodates the communal library since the cha-racter of the library suits the introvert character of the monolith. Thus, the library is both a private territory of the guest room and a public territory of the community. If residents would like to enter this communal library, they have to pass a narrow pathway in the monolith. Furthermore the colors in the communal library correspond with the colors in the monolith. In an architectural sense, residents perceive this narrowness in combination with the coloring as ‘entering a private territory’.

In order to provide a contrast-color environment, the walls are colored blue in combination with an orange colored flooring. This blue color strenghtens the closed character of the monolith.

The combination with orange is used to create a complementary contrast. A complementary contrast is defined as a pair of colors, that are of “opposite” hue, placed next to each other, to make each other appear brighter. I have made this design choice since my interviewees reflec-ted that bright colors are needed in order to keep Alzheimer’s patients lively.

According to van de Plaats, most Alzheimer’s patients experience what happens behind their back as not existing (Plaats, van de, 2008, p.25). Therefore the monolith is designed closed towards the community and open towards the quiet garden. Since the most activity takes place in the community, guests experience this as inexistent.

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TRANSIT Community

Monolith

Tom van Alst

TRANSIT Community

Shell

Tom van Alst

Shell 4./ 5.

Monolith, photographed from the outside

A balance seeker benefits from a semi-active environment, which means that the guest room, called the shell, has a semiclosed character. In the following quote, van de Plaats describes the particular needs of the balance-seekers: ‘Balance seekers are also called ‘ex-wanderers’. Because of their physical disability these type of Alzheimer’s patients cannot wander around to search for impulses. However they still need an average amount of impulses in order to feel lively’ (Plaats, van de, 2008, p.44).

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TRANSIT Community

Shell

Tom van Alst

Thin shell structure

TRANSIT Community

Shell

Tom van Alst

Peek notches 6.

Shell, photographed from the outside

Van de Plaats describes that balance seekers are fond of abstract visual impulses such as motion stimuli of human bodies (Plaats, van de, 2008, p.44). It is thus important to have an interaction between the shell and its surrounding. Therefore, the thin shell structure is provided with peek notches.

As these notches are small, guest can observe parts of the passerby so that the visual impulses remain abstract. Furthermore the shell is open towards the active garden. The nature of the active garden provides a calming effect on balance seekers and simultaneously the activity in the garden provides them the needed amount of impulses.

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The interior functions, as the bedstead, the wardrobe, the shower, the sink, the bathroom cabinet and the toilet, are molded into the thin walls. This type of design is called a thin shell structure. As the walls of the shell are shaped by the forms of the inside interior spaces, this is symbolic for ‘exposing the inside’. This notion suits the semi-closed character of the shell.

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TRANSIT Community

Shell

Tom van Alst

TRANSIT Community

Open kitchen 7./ 8.

Photos of the shower and the toilet in the Shell.

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The territory of the shell is flexible since the guest room accommodates one of the open kitchens. The vibrant character of the open kitchen suits the character of the guest room. A part of the open kitchen is colored pink, which corresponds with the color of the walls in the shell.

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Shell

Tom van Alst

TRANSIT Community

Colored space

Tom van Alst

Colored space

TRANSIT Community

Colored space

Tom van Alst

Optical illusion

A wanderer is an extrovert person, which means that the guest room should have an open character. According to van de Plaats, wanderers constantly need to receive impulses in their room. Therefore, the guest room is located by the most active space: the biggest open kitchen. This space provides the wanderer with visual as well as audible impulses. The guest room is defined by colors on the existing walls and flooring of the open kitchen. Visually, these colors create the private territory of the guest room but simultaneously it remains a public territory for everyone. The red walls in combination with a green flooring accomplishes the complementary contrast in the guest room.

These colors suit the open and active character of the colored space.

Van de Plaats asserts that Alzheimer’s patients have difficulties with estimating depth in space when similar colors are used (Plaats, van de, 2008, p.77). In the design of the guest room, this limitation is used as an optical illusion. Vertical surfaces on different walls, located on spread positions in the building, are colored similarly so that from a certain optical standpoint these surfaces become a ‘colored wall’. The wanderer will not experience the spread positions of the surfaces because of the optical disability of the Alzheimer’s disease. Symbolically, the physical territory of the guest room covers a large part of the building since these colored surfaces have spread positions. This corresponds with the idea that a wanderer uses communal areas, as the circular pathway, as part of their private territory. Therefore the colored space is situated on the circular pathway.

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TRANSIT Community

Colored space

Tom van Alst

TRANSIT Community

Colored space

Tom van Alst

Public bath room 9.

Inside the colored space.

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Colored space, photographed from the outside.

11. ‘Bed room’ area in the colored space.

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The colored space contains a double bed, a wardrobe, a cupboard and a seating area in an open setting. The guest room does not have a private bath room. Instead, guests make use of the existing public bath room since this is a closed space where guests can have their privacy.

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Space and Surveillance in the Age of Digital Mobile Media

Introduction

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

Space and Surveillance in the Age of Digital Mobile Media

Ricky van Broekhoven

This makes it possible for us to inter connect with almost every person on the planet. It has become an inescapable part of our lives and with this, our personal space becomes placed in a new context.

The smartphones through which we link to the web have become embedded in our society. With this medium we are always connected to the ever-flowing data stream.

Digital developments increase exponentially. In this era privacy is regularly re-exposed. Everything we write, post, down- and upload albeit passively or actively, is being recorded and analyzed on the web. This ‘geodemographic’ information is the gold of the 21st century for governments and enterprises. This can be an oppressive thought. Socrates was against the written word, could this era be the point where we lose control of the means through which we communicate? What is the influence of these ‘connected’ mobile media on public space? In this thesis I explore this question by elaborating four topics: Personal space,

“ And never have I felt so deeply at one and the same time so detached from myself and so present in the world ” Albert Camus

The philosopher Socrates didn’t document anything of his work. He used the dialectic approach; conversations. The written word was something he didn’t believe in because in order to communicate he believed there should be physical contact.

Eventually printing and writing contributed to the documentation of the past and cultural growth of societies. In combination with the technological developments, the capability to write has made that we now live in the age of wireless digital communication via the Internet.

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Introduction

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Space and Surveillance in the Age of Digital Mobile Media

Introduction

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

cocooning, augmented reality and online surveillance.

In the first chapter I use Edward Hall’s concept of proximity to find out what personal space is. It is something that we are daily confronted with in many different occasions, but personal space becomes more apparent when we participate in public space. As a regular train passenger, I make Hall’s theory more tangible in the second chapter by explaining the unwritten rules of behaviour in the context of Dutch trains. I also want to answer the question how and what kind of space we embody while we are ‘cocooning’, when we are using our digital media to create our personal space. In chapter three I explore the encounters of the virtual with the material world. A decade ago the computer was a portal on a fixed location. Nowadays this portal has become mobile. Applications of ‘augmented reality’ offer extended experience of physical space. How does this evolve? With the emergence of the smartphone the amount of users of mobile

Introduction

Ricky van Broekhoven

Internet is increasing exponentially. We are addicted to data and we feel the need to virtually engage with each other, but this does not go unnoticed. We are being monitored and our actions are analysed. In this chapter I want to explore the consequences of this.

I conclude in the final chapter by referring to my findings and relate them to my position as a designer.

I would like to thank my mentor Margaret Tali for her expert advice in realising this thesis.

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Space and Surveillance in the Age of Digital Mobile Media

Introduction

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

The notion of personal space

Ricky van Broekhoven

The notion of personal space Humans we are made of flesh and blood. Inside us there are organs which each fulfil one or more tasks. The stomach digests the food; the intestines subtract the nutrients out of it. The lungs extract vital oxygen from the air and release carbon dioxide, while the heart is pumping blood throughout the whole body to make sure none of the organs lacks their supply of oxygen. Our skin is our biggest organ being 16% of our total body volume. It is a special organ. It is not only protecting our insides and helps us cooling down while sporting or isolating the heat in the winter; it is also one of our five senses. Inside it are billions of receptors, which are taking in information and transferring that to the brain where the information is being processed and necessary action is undertaken.

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People using the smartphone at the trainstation

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Space and Surveillance in the Age of Digital Mobile Media

The notion of personal space

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

Like animals we are multi cell organisms. When observing the world of fauna, it is like looking in a mirror, we can see a reflection of our own behaviour.

A famous example is that of birds sitting on a fence separated by a measured space.

They deliberately leave a very specific distance between them and their neighbours. When a congener is coming to close, this results in a fight or withdrawal. There seems to be a critical distance, which is instinctively interpreted as threatening. For every species, this distance is different, and for some even non- existent, but it is always predictable and consistent. Like animals, our physical body is surrounded by this invisible bubble. In this chapter I want to elaborate the notion of personal space. What are the effects of personal space?

The bubble of personal space is part of our palette of communication tools through which we interact with our lovers, family, friends, colleagues and strangers.

Although it is predictable, it is not static.

The notion of personal space

Ricky van Broekhoven

On the contrary, it is very flexible and its range seems to change all the time. The anthropologist Edward T. Hall in his book The Hidden Dimension (1966) did an elaborate qualitative research to the phenomenon of personal space, which gives it perspective and tangibility.

Hall analyzed for this study the non- verbal communication. He coined it the as being the science of “proxemics”. According to Hall there are four critical distances (Hall 1966) in which we demonstrate specific behaviour. We vary between these four by inflating, deflating or merging our personal space. Although it must be said, these are very arbitrary, and culture and society related. Within his argument he refers to middle- class Americans in the 1960’s. I am from a different time and place, I live in the 21st century in Northern Europe, but thinking of my everyday life, I can identify by Hall’s observations.

‘At intimate distance, the presence of the other person is unmistakable and may 56

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Space and Surveillance in the Age of Digital Mobile Media

The notion of personal space

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

at times be overwhelming because of the greatly stepped-up sensory inputs. Sight (often distorted), olfaction, heat from the other person’s body, sound, smell, and feel of the breath all combine to signal unmistakable involvement with another body. ‘ (Hall 1966, p.116) Hall argues that for every distance there is a close phase and a far phase. In the quote above he describes the closest phase physically possible; that of body’s involved with each other. Distance receptors like ears and eyes are reduced. Touch, taste and smell are now dominating. This form of intimacy usually does not take place between two strangers. There has to be a kind of bond, like love or physical attraction. If one enters this close intimate phase un- invited this can evoke a strong sense of rejection, and ultimately even be traumatizing.

In the far phase intimate parts of the body are not touching but they are within arms reach. Details of the face and the eyes can easily be seen. The far intimate phase

The notion of personal space

Ricky van Broekhoven

is only one step away. This is the phase in which strangers can often find themselves.

Like in a crowded elevator in a shopping mall, or the delayed train during the rush hour. Bodily contact is inevitable in these scenarios. It is virtually impossible to move and stand without arms or legs touching.

This phase can be confronting, within this distance body heat is noticed and odour of ones breath can be noticed. Here the body mechanism of defence is set in use. Our muscles are cramping up, when touching the other body withdrawal occurs. We try to be as immobile as possible. Relaxing or enjoying bodily contact is taboo.

The personal distance in the close phase (approx. 50 to 75 cm) allows the participants to hold or grasp the person.

To stand within reach, like friends having a drink in a bar or a toddler within who is kept at arms length of the mother. Within the far phase (two and a half to four feet) physical contact is usually not possible but details on the face and body can easily be observed.

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Space and Surveillance in the Age of Digital Mobile Media

The notion of personal space

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

Embodiment of space through mobile media

Ricky van Broekhoven

Embodiment of space through mobile media

When you ask a shopkeeper for advice, or you are in a random talk with a stranger, you find yourself in the range of the social distance. Within this distance the eyes allow the body of the participant to be seen from the waist up. Within the far phase the whole outline of the body is visible. Physical contact demands an effort. The last zone is that of the public distance. Communication often goes only one way like a person giving a presentation to 20 people. When regarding the far phase this can be perceived as the forbidden aura, which encircles the sender, like the space that surrounds the space of for example famous movie stars.

We consciously and sub- consciously are adjusting our bubble of personal space to adapt to situations where we are confronted with others in public places. It is a tool we apply on ourselves to maintain our well being and our level of social behaviour.

I commute regularly between Amsterdam and Eindhoven. The ride takes almost an hour and a half. For almost 8 years I regularly use several means of public transport actively. Public places where people reside for a while, like parks and squares, are usually open and allow freedom of movement. The Vondelpark in Amsterdam for example is a place for leisure time but it also offers a pleasant route alongside ponds and meadows when going to work by bike or foot. The park functions as a place to dwell for experiencing qualities that the home does not offer. Unlike the parks, the public transport asks of the travellers to dwell in a compact closed off space that is ergonomically shaped to fit a number of average sized people. Also usually there is a walkway which, depending on the type of transport, serves as a buffer for luggage or people in overcrowded delayed trains.

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Space and Surveillance in the Age of Digital Mobile Media

Embodiment of space through mobile media

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

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E.T Hall’s science of proxemics

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Embodiment of space through mobile media

Ricky van Broekhoven

The seating arrangement in the Dutch train offers several possibilities of use.

The system consists of double seats situated in rows mirrored vertically over the walkway, or in a horizontally mirrored configuration where the seats are facing each other.

The first one offers a small compartment of 2 persons while the latter offers space to 4.

Being an experienced train user I mastered the unwritten rules of seating culture in the Dutch train. The main objective is to avoid entering a stranger’s personal space. This is just done by keeping as far a distance as possible.

The process of picking a seat already starts when the train enters the platform and I start looking for the least crowded coach. When entering the coach I scan the space for empty seats, starting with the nearest one. The first check is for the double seater since in the worst case I have to share this with one other person. When they are taken or offer only one seat I look for the 4- seaters, and by this make the concession 63

Space and Surveillance in the Age of Digital Mobile Media

Embodiment of space through mobile media

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

to share my space with not 2 but 4 people.

When the only option is to share a space, within the 4- seaters, new options occur. Here 2 seats are facing forwards and 2 backwards. Most people prefer to travel facing forward since than it is possible to anticipate on what is coming. These are the first seats to be picked, preferably the window seat. Second option is then, to pick the seat crossways to the forward facing window seat. The reason for picking this is that both travellers have space to stretch their legs, thus having more freedom of movement and expansion of the personal space without interfering with the person sitting opposite of them. This ritual of picking a spot which is done unconsciously is not just my preference but, as I noticed, that of many other commuters as well. If I eventually found a seat and a stranger enters my personal space without using this general Dutch picking protocol, this can lead to agitation.

Jason Farman uses the notion of embodiment by Paul Nourish in his book

Embodiment of space through mobile media

Ricky van Broekhoven

Mobile Interface Theory (2012) “Embodiment is the property of our engagement with the world that allows us to make it meaningful [...] embodied interaction is the creation, manipulation, and sharing of meaning through engaged interaction with artefacts�

(Farman 2012, 23). The example in the previous paragraph illustrates how commuters in the Netherlands embody a public space like a train. In places we reside for the necessity of travelling, we tend to embody it by creating our personal cocoons in order to not having to fully engage.

Usually we tend to do this when filling up in between time, for instance when travelling. Cocooning is practiced for example through music players, a book or by taking a nap. We choose not engage in the material world, but instead dwell in our personal mental space.

During the last few years I noticed an undeniable change that has taken place.

Nowadays while travelling by train people are staring at a little device in the palm of 64

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Space and Surveillance in the Age of Digital Mobile Media

their hands. The smartphone has emerged and is gradually becoming more and more embedded in society. This multifunctional device, as well as similar mobile devices which offer Internet connection, are making it possible to continuously stay connected to the ever-expanding flow of data and social media.

When cocooning we choose not to fully take part in the material world around us, instead we choose to dwell in the virtual world. Via apps and social media we are now gaming with friends or we are engaging with like-minded people on social platforms.

The virtual world is expanding rapidly end the possibilities are endless.

A big shift has been brought along together with the mobility of this virtual space. When Internet was becoming the standard in the 1990’s we had to find a computer with an Internet connection in order to log in. Nowadays mobile media devices make it possible to log in almost anyplace, any time.

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Farman elaborates on this phenomenon in Mobile Interface Theory. He argues that the development of the smartphone- embedding is of influence on how we deal with, or embody space. “... mobile media cocooning points to what initially drew me to the study of mobile media in the first place: the use of these technologies demonstrates an intimate relationship between the production of space and the bodies inhabiting those spaces.� (Farman, 2012. p.9) Here he points out that there is a strong conjunction between shutting off from the present material world via cocooning and at the same time actively engaging in a virtual world. By the use of mobile media we have found a new way to interact with the physical world around us.

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When virtual meets physical

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When virtual meets physical

Space and Surveillance in the Age of Digital Mobile Media

When virtual meets physical

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computer, a non- mobile space. The web could be entered in a library or an Internet cafe, but most of the households in the Netherlands also had their private computer standing at home. This could be consulted any time. Internet providers advertised for their best deals. The bandwidth seemed to grow by the year offering faster streaming and downloading. Simultaneously the same thing happened for the network of our mobile phones. The development in the capacity rapidly made it possible to have an Internet connection almost everywhere. The network standard is called 3G, meaning the third generation of mobile data network which offers usage of internet, not very different from the ‘fixed’ connections. The portal, which once was fixed, is now mobile. On the one side the physical world where the hand holds the smartphone, or where the notebook sits in the lap, and the virtual world on the other side of the screen.

The word virtual derives from the Latin word ‘virtus’, and had meanings like

The computer is a portal. Through this device it is possible to connect with friends, be updated with the world news, have access to images and videos, or find information on just about any topic you can think of, to put it differently, there is way more to be found on internet than you can ever even think of. Like our physical universe, also the databank of the web is expanding. When being a young boy I imagined that there was a ‘book of answers’. You never had to remember or to learn anything since all the knowledge of the world was written down in this book. You only had to always bring it with you. By now, in a way different from what I could dream of, this fantasy has become a reality in the form of the mobile Internet.

Just recently it was very normal, when there was a need to log in to the web, to find an Internet connection on a fixed 68

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When virtual meets physical

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Space and Surveillance in the Age of Digital Mobile Media

‘virtue’, ‘power’ and ‘force’. In the 16th century the term was also used in relation to metaphysical ideas around Christianity.

In 1959 virtual began to be used in computing terms. Farman (2012, p. 37) argues that virtual is an emulation of the physical. Then the question rises, to what extend can the virtual replace the physical?

When we explore an unfamiliar city while being on our holiday, a mobile medium that we often use is a map. The physical world is represented on a two dimensional piece of paper, according to Farman an emulation, a virtual reality. Could this paperwork be a replacement of the space?

Farman uses a reflection on this topic by Umberto Eco, “...once there is a 1:1 relationship between the representation and the thing it represents (such as a map that is the exact size of the space it represents), the former will destroy the latter” (Farman, 2012, p.37). According to Farman, virtual is not a replacement of the physical. He argues that “... The virtual is instead an experience of

When virtual meets physical

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multiplicity, it is an experience of layering”.

(Farman 2012, p.37) Virtual is an addition to the physical.

‘Augmented reality’ is the most literal example of a virtual layering. It is the placement a virtual object, or layer, in the actual world. Several app’s on our mobile devices explore the possibilities of augmented reality. ‘Layar’ is a clear example of this. When having the application enabled, it uses the locative functions like GPS to add a virtual image of your interest on your camera view. Information, which is invisible or unknown, in this way can add extra depth to a location. The virtual adds to the material. To illustrate this The Stedelijk Museum is currently using Layar for exhibiting work of Jan Rothuizen. At several locations throughout the museum his work can be seen only through the mobile devices.

When visiting a historical site, for example the Duomo cathedral in Milan, to find out more about the background and history of that place on the spot, very much 70

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When virtual meets physical

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Space and Surveillance in the Age of Digital Mobile Media

strengthens and deepens the experience.

Coming back to the previous chapter and the definition of embodiment by Paul Nourish, “...our engagement with the world that allows us to make it meaningful” (Farman 2012, p.23) relates very well to this phenomenon.

This placement of virtual layers over physical reality is only in the start- up phase and the techniques to use it are often slow and are not working fluently. Nevertheless ‘tech- artists’ are happy to explore its endless possibilities, since in the virtual world Newton’s gravitation rules, or Einstein’s theory of relativity do not apply.

In the virtual world you can define your own rules. Artist and computer scientist Sander Veenhof for example made a virtual installation of over 7.500.000.000 coloured cubes floating above the earth surface. Installations of this mega- monumental scale could never be realized in the material world. Because of this, augmented reality is slowly getting embraced and commercialized. It is compa-

When virtual meets physical

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rable with the first 28kb overseas modem connections which made it possible to chat in real time with some one on the other side of the globe, and the contemporary internet connections which allows us to stream, download and upload anything that is digital, in merely seconds. Augmented will be the future.

In spring 2012 Google gave a preview of their ‘Project Glass’. Within this project the company explores the possibilities of a pair of glasses with a translucent digital layer on it and having full smartphone functionality. The first thing that probably pops up in one’s mind are eighties science fiction movies like Robocop and The Terminator.

The reality that Google created is not much different from them. The first prototypes are already being tested. They aren’t able to see through walls, spot your enemies at a distance, and have a ‘body count’ running in the corner of your eye, but they constantly emit and receive location- based data, which they show the wearer. Looking outside with 72

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When virtual meets physical

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Space and Surveillance in the Age of Digital Mobile Media

Addiction for Data and the Society of Surveillance

Ricky van Broekhoven

Addiction for data and the society of surveillance

the glasses give you instant information about the weather. The agenda shows a to do list for the day. When walking outside, it provides you with information of possible road- blocks and detours while in the meantime you are talking to friends and listening to music. The relatively young smartphone, which is getting embraced by the world community, is already evolving from a semipassive device in the pocket or the handbag, to a pervasive device without an interface, which continuously provides you with information on the go. The virtual layer that is added by the mobile devices is going to be a very real part of our everyday life.

For some reason the telescreen in the room was in an unusual position. Instead of being placed, as was normal, in the end wall, where it could command the whole room, it was in the longer wall, opposite the window. To one side of it there was a shallow alcove in which Winston was now sitting, and which, when the flats were built, had probably been intended to hold bookshelves, By sitting in the alcove, and keeping well back, Winston was able to remain outside the range of the telescreen, so far as sight went. Orwell, G. (Nineteen Eighty four) A while ago I joined a workshop escorted by visual artist Sander Veenhof at the Stedelijk Museum in Amsterdam. He presented some of his work that plays with the borders between the virtual and the material world. As I could relate with his work we got into a conversation on contemporary 74

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Space and Surveillance in the Age of Digital Mobile Media

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mobile media devices in public space. He compared checking the mobile phone for new possible messages or notifications, and the need to instantly react, with the urge for having a cigarette. This comparison struck me because all of a sudden I realized how often I use my Iphone.

Let’s say a heavy smoker lights a cigarette once in an hour. Compared to the use of my smartphone that sounds reasonable. In random situations I check my phone at least three times per hour. This number is higher when I am waiting, for example, standing in line for the cash desk in the supermarket. When I am travelling the frequency of use is even higher than that.

In these moments when less engagement in the material world is expected of me, I will eagerly catch up with checking the news sites and the emails, updating with my friends activity on Facebook, Path and Whatsapp, watching missed television shows and play games. During the time I am travelling my phone will be in my hand for

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View through Google’s Project Glass

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the whole ride. And I am no exception in this.

You could say, in the western world where the mobile Internet network is well covered, the majority of us is suffering from an addiction of data. Apparently we feel an urge to engage with the virtual world.

This was the case ever since the Personal Computer became connected via the Internet, and became even stronger with the emergence of web 2.0 at the beginning of this century. As a part of this new standard, which we still use today, anyone can contribute by uploading data, commenting and sharing knowledge. When I was younger my brother, sister and me were always fighting for the ‘computer time’, or so to say ‘virtual time’. We had only one seat, nowadays when we are together we each have our own smartphone or laptop connected to the Internet.

Web 1.0 was merely a one- way communication, making the PC a kind of interactive television. Web 2.0 serves the sharing of information between groups and

Addiction for Data and the Society of Surveillance

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people. Like in the material world, we tend to group up with friends and like- minded people online. En masse we use our ‘Like’ button in Facebook, initially not realizing that we are digitally being monitored, and that our commenting, liking and sharing was sold for great amounts of money to companies to whom this recorded interaction is of great value to for tuning their services and products.

The Canadian information scholar David Phillips describes this type of knowledge production. According to Phillips there are two types of monitoring, which are of big influence to the negotiation of space and identity. He distinguishes between ‘visual’ and ‘actuarial’ surveillance. (Phillips, 2012).

He describes visual surveillance as ‘... a differential unbounding of space, through enhanced or extended visuality or cognitive awareness.’ An example of this is CCTV (closed circuit television). Cameras register the activity of the place of surveillance. These images are than recorded and monitored.

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Addiction for Data and the Society of Surveillance

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Addiction for Data and the Society of Surveillance

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The society is structured and organized in a way that the only purpose in life is contributing to ‘The party’. A tool of surveillance that the Party applies to discipline the citizens are the ‘telescreens’. These are implemented in every house as well as public areas.

They display propagandist material while at the same time having the function of surveillance cameras. It is impossible to shut them off. As a citizen of the superpower ‘Oceania’ you never knew when you were being spied on like it happened to the main character Winston Smith. Although Orwell wrote the book more than half a century ago in 1949 it is remarkable how his idea of the telescreen and the contemporary actuarial surveillance via Internet have such close resemblances.

There is only one fundamental difference between Oceania- citizens and us. They didn’t choose to be spied on. We do.

With our smartphones and mobile Internet subscriptions, we quench our thirst for data by downloading apps that make our life convenient and fun. Through Facebook

A more profound mode is that of actuarial surveillance. ‘In it’s idealized form, actuarial surveillance individualizes each member of the population, and permits the observation and recording of each individual’s activities, then collates these individual observations across the population...Actuarial surveillance as a technique of knowledge production and population management is becoming a central organizing principle of modern institutions’ (Philips, 2012). It is not a secret that we are being spied on. In the beginning of the Internet our digital actions like search queries on Google were already of big value, but ever since the Internet has gone mobile, and our digital actions are linked to physical places our geodemographic data is becoming more elaborate and detailed.

Contemporary surveillance is reminiscent of George Orwell’s Nineteen eightyfour (1949). This dystopian novel is situated in a world that is divided into three superpowers, which are in a constant state of war.

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we share our status of activity. We inform our Facebook friends on our everyday important and less important adventures and we are happy to share our comments to others. With the convenient mobility of the smartphone our shared knowledge is instantly linked to a geolocation. Facebook puts these statistics on the market. To Facebook the users account information is their merchandise (Teeffelen, www.trouw.nl).

Large enterprises and governments buy this data to make ‘geodemographic’ analysis.

This links geolocation with other personal data, in order to produce statistical identity categories. These categories, or Foucault’s disciplines, are then applied back on us in for example marketing strategies.

Like Facebook, Google is another source for geodemographic knowledge.

Their Project Glass triggers one’s imagination. It shows a future with an interface-less mobile connection, or like Farman (2012) describes it ‘ubiquitous’ computing. You only have to wear the glasses and Google 82

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automatically ads layers on the glass to constantly supply you with information. But this project is also Janus- faced. By wearing the glasses, Google is not only able to track your location and monitor your actions, but they are also able to manipulate your behaviour on the go. Imagine the possibilities it offers for advertisers to draw your attention.

While wearing the interface it persuades you into buying products.

The system of mobile surveillance in which we participate seems impossible to escape from. Orwell’s character Winston hides in the alcove in his room to not be seen, but this doesn’t allow him to speak freely, since the telescreen registers the sound. To spent time with his girlfriend and plan a revolt they risk their lives by very secretly renting a place where there is no telescreen mounted. Our mobile media have become synchronized to our identities and are serving the function of the telescreen.

They are the one- way mediator between us, and the influential enterprises like banks, marketers and insurance companies.

Space and Surveillance in the Age of Digital Mobile Media

Conclusion

Ricky van Broekhoven

Conclusion

Space and Surveillance in the Age of Digital Mobile Media

Conclusion

Ricky van Broekhoven

computer that was connected to the 28Kb modem was a portal through which the virtual world on the other side of the screen could be entered. An important shift that occurred at the beginning of the 21st century is the evolving of web 1.0 to web 2.0. Internet then became a two-way communication system. Social media platforms came into existence and it became a way of profiling yourself online. An important shift in the digital revolution is that this portal became mobile. This puts cocooning in a different light. It changes the way we embody spaces. When sitting in the train and having the smartphone in the palm of one’s hand, our engagement with the material world is low.

But simultaneously the involvement with the virtual world behind the screen is high.

The virtual and the material world are not two separate manifestations of reality. The first is an addition to the latter.

In augmented reality virtual objects are connected to a GPS location, which can be made visible to the spectator with a smart-

Human beings in a western society are constantly put in situations where adaptation of personal space is needed. Consciously and subconsciously we are inflating, deflating or merging our bubbles of personal space in order to maintain our level of wellbeing and social accepted behaviour.

Especially in the situations where we have to deal with strangers who come within arms reach, like in a crowded train this ‘adjusting’ of the bubble becomes very apparent. An example of this is creating our personal cocoon. We read a book or we listen to music over the headphones to not have to socially engage, instead choose to dwell in our personal mental space. Recently something was added to this cocooning.

The increasing use of the smartphone and other digital mobile media introduced a new era.

We are on the verge of a world changing digital revolution. Internet is already implemented in most households for almost two decades. In the beginning the 84

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Conclusion

Ricky van Broekhoven

Space and Surveillance in the Age of Digital Mobile Media

Conclusion

Ricky van Broekhoven

knowledge of your physical behaviour can also be extracted. This geodemographical data is then applied back to us, implemented in business strategies. With the knowledge of online user- behaviour connected to the future of pervasive ubiquitous computing, social media platforms and large enterprises have a tremendous amount of power. As addicted data consumers we seem committed to this system.

Personally I am a happy consumer of my Iphone and it became embedded in my life. It offers me instant knowledge and it literally guides me through the city of Amsterdam where I just recently live. It also keeps me updated with my friends and their activities. Very often I think my freely downloaded applications are very useful and inspirational. I am aware that my search queries and activities are being monitored, but I don’t feel over controlled or imprisoned.

As long as I still have the power to log out of the data stream.

phone. Current programmes do not allow for fluent use of these virtual layers, since available technology doesn’t allow this yet.

But artists have explored the endless possibilities that augmented reality could offer for several years. The example of Google’s Project Glass shows that this development is an inevitable part of the future. This provides the wearer with information of their interest on the go so there is no need for an interface. We are entering a future of interface less, ubiquitous computing with virtual layers.

Within the western world we are getting addicted to the data- stream. Our online behaviour is even more active with the mobility of the Internet. Our actions do not go by unnoticed. Most providers of online applications are Janus- faced and offer an elaborate embodied experience, but they are simultaneously selling information of your online behaviour to companies and governments. With the coming of the geolocation, where the mobile media can be tracked, 86

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Conclusion

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Invisibilis Radialis Sensorum

Research

Ricky van Broekhoven

Invisibilis Radialis Sensorum / Research

I’m not afraid or reluctant of the technologies that the future brings and I embrace the new technologies and possibilities.

But I am also a persevering supporter of physical contact. In my opinion the engagement with physical space is a multi- sensory experience that can’t be replaced by any virtual or augmented reality. The technologies of the future should be put in to give extra quality and layers to the encounter with material space. I believe a balance between pervasive- virtual and material will define the sense of well being of the 21st century.

My goal as a designer is to explore this equilibrium.

As a little boy, I used to imagine the book of answers. You never had to remember anything since everything you wanted to know was in the book. You only had to bring it with you. Now this fantasy has come true in the shape of mobile internet, and even better it also allows us to have embodied engagement with our friends like via video calling. The smartphone is the new device to constantly stay within reach and allows you to link to the world. This technology is there but how does that affect the space in which we live? As I travel by train, wich I do a lot, I see almost every commuter cocooning behind their phone.

The graduation thesis I wrote was about this topic and dealt with personal space, and the role of virtual in relation with physical. The more research I did the more I found out how the mobile media would become deeply embedded in our society.

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All our behaviour on mobile media is tracked, monitored stored and sold. And finally, I can speak for myself since I know I’m not the only one that feels dependant of my internet connection, I think we can speak of a worldwide data addiction.

Invisibilis Radialis Sensorum

1.

Mobile telephone activity 07.00 AM in the Netherlands

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When doing the research for the thesis and coming to these ambivalent conclusions on a more psychological level, I started to wonder; what do we deal with?

How is it even possible that all this traffic is going on around is ? What is this ‘thing’ that makes it possible to wirelessly transfer music, surf the web, watch movies, and download any file I want, apparently from thin air. What does it look like? I found out the wavelenghts and the formulas the calculate how to block them.

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1.

Wavelenght calculation 2.

UMTS antennas

WIFI = 300000000 / 5500 mHz

= 5,4 cm

GSM =

300000000 / 900 mHz

= 33 cm

3G =

300000000 / 230 mHz

= 130 cm

Invisibilis Radialis Sensorum

UMTS, 3G and hybrid Antennas in the vicinity of ARCAM in the centre of Amsterdam

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2

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Invisibilis Radialis Sensorum

Research

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Invisibilis Radialis Sensorum

Research

Ricky van Broekhoven

Mobile devices allow us to connect instantly every person on the planet that is connected via the web to the other. This to me is a very beautiful thing and coming back to the book of answers even a dream come true. But there is a price we pay for it. These waves are meta- structures of our cityscapes. We pollute the air with potentially harmful radiation which many researches point out. I found out I could make it more tangible by making it audible. So I did a research to the sound and making invisible high frequency EMF radiation by electronic and wireless devices audible and physical.

We have surrounded ourselves with antennas and devices alike to make mobile communication possible. I found out there are 25388 antennas scattered over the Netherlands to cover our communication network for wireless internet and gsm. The highest concentrations are in the city where a lot of people live.

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Devices to make EMF radiation audible.

Invisibilis Radialis Sensorum

Concept

Ricky van Broekhoven

Invisibilis Radialis Sensorum / Concept I wanted to design an interaction with this invisible radiation. “Invisibilis Radialis Sensorum�; a spatial parasite that grows when it senses EMF caused by smartphones. When Invisibilis Radialis Sensorum starts to grow it wants to occupy space.

And by doing so making usable space dysfunctional. I want to make the invisible meta structures physical.

So I did a physical research on creating a space that could come alive reacting on the EMF. And so becoming a meter.

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Concept

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Inflatable models racting on EMF radiation.

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Design

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Invisibilis Radialis Sensorum / Design Scattered over the graduation exhibition lies the spatial parasite. When it senses EMF radiation caused by a phone it reacts by growing in space.. It influences the user of the space; more use of smartphone means less accessibility.

I analysed the space and divided it in several islands that are meant for a specific function. I mainly wanted to focus on the exhibition part because there physical engagement with the work is important. So I created several islands for each exhibitor, the lecture and bar space I used inflatable material since then I was able to make the radiation very tangible because it literally could crow. It is transparent to not lose the links between the works, but make an obstacle in space.

The design is surrounding us, as is the EMF all around us. As it grows it becomes hard to walk around it, but it is possible to see 99

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Design

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Invisibilis Radialis Sensorum

through. Slowly it tends to dominate also the left over pieces of the room. If demands engament and interaction with physical space.

An EMF sensor I built is at the entrance since this is the place where I want the user to be informed and evoke interaction. The sensor triggers a blower. By slowly inflation and deflating, reacting on the radiation the space becomes alive. It is possible to enter the organism and experience the negative of the space.

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The Agency of Touch: Engaging Alzheimer’s Patients

Abstract

Jack S. C. Chen

The Agency of Touch: Engaging Alzheimer’s Patients

The Agency of Touch

Jack S. C. Chen

technology) was used to understand the act of bare-skin touch. Engaging physically allows the patients to interact with their loved ones and caretakers better, thus impacting the well-being of both parties towards the better. Given the social and cultural barriers related to touch, I have searched for ways in which a design object can transcend these barriers. My research resulted in distilling artifacts and design qualities that promote and sustain the engagement of Alzheimer’s patients through touch. My thesis contributes to new conceptualization Alzheimer’s patients needs and related design for this user group.

Engaging Alzheimer’s Patients The focus of this thesis is set on the sense of touch as an agent for human engagement. I argue that developing an understanding about the possible existential experiences of Alzheimer’s patients is the foundation for designing for this user-group.

I began from examining the essential role of our haptic organs through which we gain existential knowledge. An insight into the hierarchical relationships between the senses allows me to bring forward the scenarios of existential perceptions that are in par with the experiences of Alzheimer’s patients.

Further, I have applied researchthrough-explorative-design as my design method. The concept of ‘embodied interaction’ (borrowed from the field of information 104

Abstract

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The Agency of Touch: Engaging Alzheimer’s Patients

Acknowledgements

Jack S. C. Chen

The Agency of Touch: Engaging Alzheimer’s Patients

Acknowledgements

Jack S. C. Chen

Acknowledgments people and have made many friendships.

These encounters have given me much inspiration and critical thinking. I would like to thank Henri Snel and Allard van Hoorn for their mentorship and optimism. I would also like to thank Margaret Tali and Lucy Cotter for their theoretical support and constant challenge to think critically.

The Class of 2012 is the first graduating class of the Masters of Interior Architecture from Sandberg Institute. Suffice to say we have made many wonderful memories together. I would especially like to thank “the poets” Dennis Schuivens, Ricky van Broekhoven and Alonso Vazques, as well as Tom van Alst, Vicki Law, Ly Num, and Sabine Ruitenbeek for their intellectual, spiritual and emotional support.

Last but not least, I would like to thank my family for their encouragement and continuous support of my endeavors: My wife Anna & son Joa. My family in the States and the Tummers Family here in The Netherlands.

This research project stems from my internship experience at a nursing home in Haarlem. I would like to thank Michiel Beijer and Stichting Sint Jacob for opening up their resources for my research. They introduced me to care professionals in the field. I am thankful to Astrid van Alphen, Ingrid de Ridder and Galina Piket for their professional insights and enthusiasm on every encounter. I thank them for their patience and generosity of time to help with me in my field research. I also would like to thank Maurice Willem, Eva de Mooij, Elena Khutova, and Marieilse Bourlanges for finding the time to participating in my workshop.

The works on the Space Extender, Touch-O-Tone and Infinity Table owes gratitude to the skills and talent of several people, including Dooho Yi, Jan-Kees van Kampen, Anita Burato, Annemiek Van de Grint, Bart Visser, David van der Veldt and Ianus Keller. Their advice and work were invaluable. Throughout my two years in Sandberg Institute I have met many extraordinary 106

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The Agency of Touch: Engaging Alzheimer’s Patients

Introduction

Jack S. C. Chen

The Agency of Touch: Engaging Alzheimer’s Patients

Introduction

Jack S. C. Chen

Introduction ‘seeing is believing, but feeling is truth’

cultural, historical, and philosophical treatment of touch.

We have enduring cultural assumption, present in Plato and compounded in the Enlightenment, of the primacy of vision...

The lowly position of touch in the hierarchy belies in its complex constitution, being a singular sense that corresponds to no singular organ. Physiologically, touch is a modality resulting from the combined information of innumerable receptors and nerve endings concerned with pressure, temperature, pain and movement. But there is more to touch.

It is a sense of communication. It is receptive, expressive, can communicate empathy.

It can bring distant objects and people into proximity. (Paterson, 2007, p1) What Paterson states about the position of touch in the hierarchy of senses has also been echoed by architectural historian Juhani Pallasmaa while describing the essence of architectural experience and how we perceive architecture using our senses

Thomas Fuller, (1608-1661)

The British churchman and historian Thomas Fuller’s famous quote about truth is well remembered and often rehearsed. Yet in contemporary times only one side of the equation is emphasized, “seeing is believing”. This is an evident reflection on our current culture’s preference of vision over touch. The prevailing attitudes in Western industrialized cultures still maintain such sensory stereotypes as vision is predominant and distant and touch more intimate and proximal. The subjects of sight, sound, and body have been studied extensively in all areas of humanities, social science and natural sciences. However, within an academic climate that celebrates visual cultures, and being encouraged by the immersion of popular media’s infatuation with visuality, touch remains largely neglected.

Haptic scholar Mark Paterson remarked on why this is so, when tracing back on the 108

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Introduction

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Social Context

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Social Context (Pallasmaa, 2009). However, it is more specifically what Paterson remarks about the dimensions of touch as a sense of communication. This sense above all senses is more “receptive”, “expressive”, and able to communicate “empathy” that I want to highlight as the crucial characteristics applicable for this research and Alzheimer’s as its user group.

The sense of touch is especially important to Alzheimer’s patients because it is one of the last senses to go. It moreover, has a powerful effect. Research show that stimulations from touch produces hormones such as oxytocin that triggers social behavior and interest in elderly women (UvnäsMoberg&Peterson, 2005). The relevancy of this issue can be put into both financial and social perspective when we take into account the steady increase in number of the elderly citizens in the population. On top of our current population’s sufferings from global economic crisis, the increase of elderlies in the population is beginning to put a strain on retirement financing and health care systems. The number of elderly citizens requiring more frequent medical attention increases along with a need for more nursing home facilities.

According to the U.S. Census Bureau the world population reached 7 billion in 2011 and will grow to 9.2 billion by 2050. In the same time frame, the propor110

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cases will reach 35.6 million people in 2010. That number will nearly double every 20 years to 65.7 million in 2030 and 115.4 million in 2050. Current research focuses increasingly on enhancing the patient’s wellbeing. While we are still unable to find a cure for the disease, its effects and symptoms can nevertheless be lessened or countered to certain extent. Some interesting finds have surprisingly simple applications.

tion 65+ amounts to 545 million and will increase to 1.5 billion. This amount represents a surge from 7 to 16 percent of the total population. By 2050, seniors will outnumber children aged 14 and under for the first time in history. Our social landscape will change tremendously as one out of six will be 65+ years of age. In more developed countries the proportion of 65+ will most likely increase to a record 26 percent by 2050. One out of four will be 65+. Anticipating these population shifts, architects, designers and policy makers are increasingly focusing their research on the environments for the elderly and various aspects of aging.

A clearly negative effect of aging is the significant increase in the number of people with Alzheimer’s disease and related dementias. Dementia is one of the major causes of disability in later life. After 65, the prevalence (the proportion of people with the condition) doubles with every five-year increase in age. The World Alzheimer Report 2009 projects that the number of dementia 112

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Relevant Research

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Relevant Research

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Relevant Research rhythms, but also improves the mood and even decreases the rate of memory decline (Swaab, 2010, p409). Although stimulation of the biological clock improved the quality of life for Alzheimer patients and their caregivers, it is obviously not a therapy for Alzheimer’s disease itself. However, an important principle can be extracted: even if neurons are affected by Alzheimer’s disease process, recovery of function by stimulation is still possible in principle.

Another surprising project relevant to Alzheimer’s patients is “PARO” an advanced interactive robot developed by AIST, a leading Japanese industrial automation pioneer (2000). It allows the well-known benefits of animal therapy to be administered to patients in environments such as hospitals and extended care facilities where live animals present logistical difficulties.

PARO is a therapeutic robot in the form of a baby harp seal. It has five kinds of sensors: tactile, light, audition, temperature, and posture sensors, with which it can

In his recent book Wij Zijn Ons Brein (2010), physician and neurobiologist Dick Swaab discusses the possibility of stimulating braincells that had already been affected by Alzheimer disease. He proposes centering on stimulating the circadian system which is responsible for the biological clock. Nocturnal restlessness is one of the most common reasons for admission of a dementia patient into a nursing home. Our circadian system which governs our day and night rhythms is often disturbed in the early stages of the Alzheimer disease process.

The sleep hormone melatonin that originates in the pineal gland is linked to the circadian cycle that regulates its production. By introducing more light in the living environment the biological clock was able to be stimulated and melatonin production regulated.

According to Swaab, this improvement of the circadian system reduced the turmoil and unrest in alzheimer patients as well. Further studies by neurobiologist Eus van Someren found that more light not only stabilizes the 114

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The Agency of Touch: Engaging Alzheimer’s Patients

Field Observations

Field Observations

perceive people and its environment. With the light sensor, PARO can recognize light and dark. He feels being stroked and beaten by tactile sensor, or being held by the posture sensor. PARO can also recognize the direction of voice and words such as its name, greetings, and praise with its audio sensor. PARO can learn to behave in a way that the user prefers, and to respond to its new name. For example, if you stroke it every time you touch it, PARO will remember your previous action and try to repeat that action to be stroked. If you hit it, PARO remembers its previous action and tries not to do that action. His presence in care facilities such as in nursing home ‘Schalkweide’ in Haarlem has been found to reduce the stress of the patients and their caregivers.

While stimulating interaction between patients and caregivers and improving socialization of patients with each other, PARO has shown to have a positive effect on the patient’s well-being, lifting their spirits and helping them to relax.

Jack S. C. Chen

During my field research, I volunteered in a nursing home in ‘Schalkweide’, Haarlem in a span of one month. I spent time engaging with both patients and caretakers. Talking to them and helping them with little things like bringing them tea or taking walks. I also observed how caretakers interact with the patients. How they would always lay a hand first on the patient’s body and bent down to engage with their eyes leveled. Constantly stroking them or giving pressure with their hands casually along the patients’ body. Some patients who were in more severe stages were unable to speak or move much. But one can see that they were engaged with the world around them through their eyes and facial expressions. I also witnessed many times patients who were sitting for lengths of time by the dining table stroking the take top. They seemed to be in their own little world. With their eyes looking far off into the corner, while their hands were grabbing and rubbing the edge of the table as to steady themselves.

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Field Observations

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The Agency of Touch: Engaging Alzheimer’s Patients

In the novel Out of Mind by J. Bernlef (1988), the author brings us into the patient’s mind, describing the physical sensations and deteriorations of an Alzheimer’s patient body in parallel to the mental unraveling. The patient is slowly losing control of their own body and near an almost out of body experience, fleeting and floating away. The protagonist has to find something to grab to ground himself, in order to define the boundaries, and confirm his own existence.

The fingers of my left hand are numb. Put the hand on the table, palm upward. Move my fingers. Clench, relax; clench, relax. Compare with the right hand: as if there’s no current going though it any longer. Rub...rub...rub....

Grab hold of the edge of the table and let go. And again. There is activity in the space around me that is totally detached from me. Sound of water gurgling away through a wastepipe. Very successful.

Pity it stops – maybe we can imitate it...

(Bernlef, 1988, p98)

Field Observations

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...She asks me why I am rubbing the table with my hand. I look and feel only now that the hand is rubbing across the red dotted oil cloth (how long has this been going on?)...

(Bernlef, 1988, p99)

... A girl opposite me asks why I am rubbing the wood with my left hand.

‘Otherwise I can’t see the hand any longer.’

‘See?’ ‘Yes.’ ‘Otherwise you can’t feel your hand any longer?’

‘More or less. Yes, exactly. As I said.’

(Bernlef, 1988, p100).

I recognized these physical movements that Bernlef describes in the patients behavior during my field research. Further­ more, I was shown stage four patients, sleeping in their bed with hard acrylic brackets placed between the bottom of their feet and the wall. These brackets were administered in strategic locations of the body such 118

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The Agency of Touch: Engaging Alzheimer’s Patients

as hips or between the thighs to afford the patient some comfort in sleeping. The pressure created by these brackets simulated a constant sensation of being embraced or touched.

During my last visits to other nursing homes in Haarlem to interview care professionals (Jan 2012), I noticed that there is a need to address the interactivity between family-relatives and Alzheimer patients (especially in the third and fourth stages (see Appendix). In these later stages the patients become progressively unreachable due to their declining verbal and motoric abilities. Patients in the fourth stage especially seem to be very inward focused. Family members often feel powerless and sadden as they do not have a good means of reaching the patients. Family members are personally sadden to be confronted with the idea that their loved ones are no longer recognizable. Verbal communication becomes a one way stream and often the only effective way of engaging with the

Field Observations

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patients is through physical contact.

However, social and cultural barriers tends to stands in the way of what the patients need most. Touch.

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Research Questions

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The Agency of Touch: Engaging Alzheimer’s Patients

Methodology & Outcomes

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Research Questions

Methodology & Outcomes

Derived from these personal experiences, my research directions moves towards reflecting on the relationship between the sense of touch and the level of tactile curiosity in Alzheimer’s patients.

New questions have emerged to motivate both my research and design. Can touch be an agent to help patients engage more with the world around them? Can it enlarge or reverse the direction of their own field of engagement from introvert to extrovert? Can the act of touch or ‘touching’ be an agent to connect better with not only each other but with caretakers and loved ones? Given the social/cultural barriers that are related to touch, can a design object crack these barriers to give different opportunities to engage Alzheimer’s patients with the world around them? In the end, the most important questions is: Will engaging them through touch enhance the well-being of the patients and their family members?

Figure 1: Process Diagram

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Design Approach

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The Agency of Touch: Engaging Alzheimer’s Patients

Design Approach: research-throughexplorative-design

Design Approach

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interviews, field notes, video session of the interaction, voice recordings of the analysis with professional caretakers present, and workshops held with experts in the field.

Conclusions made from these field tests have given me insights into design strategies and conceptualizations that feed into the next prototype. Thus the cycle continues in order to distill qualitative parameters to formulate an effective design for the end users.

This design approach entails a process in which part of the design work is performed as part of the knowledge construction process. The outcome of such research is threefold.

The first expected outcome is the production of artifacts that will test engaging tactic focusing on touch that is in ways considerable for embodied interaction. These artifacts are seen as a mode of knowledge production. Other designers can appropriate such elements and use them generatively in new design situations.

Postulating on a design approach that will take into account ‘interactive human behavior’ and the general difficulty of designing for Alzheimer’s patients, I embarked on a research process that might be called research-through-explorativedesign (see Figure 1), which is distinguished by the following traits. A focus on ‘sketching with technology’ (Buxton, 2007), aimed at creating functional or partially functional prototypes. This is a more appropriate approach to explore issues of behavior and enactment (as opposed to envisionment).

The reason for this focus is that the kind of behaviors I am seeking emerges in use over time and are virtually impossible to sketch using less functional modes of representation. The primary mode of working would be to create experimental prototypes in the lab context and field test them at nursing facilities. Data and feedback were collected via 124

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The Agency of Touch: Engaging Alzheimer’s Patients

Design Approach

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locked in the affective parameters for an effective design object that will offer better opportunities for engagement with alzheimer’s patients.

A second expected outcome is a characterization of the qualities of the suggested solutions, abstracted to a level at which it can be reasonably claimed that these qualities inform the understanding of a whole class or genre of possible artifacts. In a design context, such understandings serve to guide upstream design work in desirable directions, as well as to guide assessment of proposed design ideas. Thus, the generative and artifact-oriented knowledge mentioned earlier works in tandem with the assessment oriented knowledge expressed as design qualities.

Finally, on the level of design strategies and directions: useful conceptualizations are formulated with the given insights gained through field tests results and the distillation of qualities that render relevant to the engagement of the end user. The speculative notion within this conceptualization helped steer the direction and application of the final design product. The evolutionary cycle of these three-fold outcomes 126

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The Sense of Touch: Existential Experience

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The Agency of Touch: Engaging Alzheimer’s Patients

The Sense of Touch: Existential Experience

Jack S. C. Chen

unconsciously internalized and embodied rather than understood and remembered intellectually. To validate the value of this type of knowledge, Pallasmaa equates the essence of ‘architectural experience’ with ‘existential experience’. Through our sense of touch we are able to gain embodied experience thus existential knowledge of ourselves.

According to Paterson, “to write about touch is to consider the immediacy of our everyday, embodied tactile-spatial experience.” (Paterson, 2007, p3 ). When we make contact with an object we are in the same time aware of the materiality of the object and the spatial limits and sensations of our lived body. Touch is the sensory mode that integrates our experiences of the world and ourselves. Even visual perceptions are fused and integrated into the haptic continuum of the self. Pallasmaa writes, “The boundary line between the self and the world is identified by our senses. Our contact with the world takes place through the skin of

To understand the sense of touch in its relevancy to Alzheimer’s patients, I return to the haptic theory of Pallasmaa.

In his book The Thinking Hand, the title proposes a metaphor for the independent and active roles of our senses constantly scanning our lived world. The subtitle Existential and Embodied Wisdom in Architecture refers to another type of knowledge and thinking.

One that hints at “... the silent understanding that lies hidden in the human existential condition and our specific embodied mode of being and experiencing”(Pallasmaa, 2009, p002). According to Pallasmaa, this type of knowledge covers many of our existentially crucial skills. Which we internalize as automatic reactions beyond our conscious awareness and intentionality. In the case of learning skills, the complex sequence of movements and spatial and temporal relationships in the execution of the task is 128

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The Sense of Touch: Existential Experience

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The Sense of Touch: Existential Experience

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He gives us cause to ponder if the prevalent mode of emphasize and value of conceptual, intellectual and verbal knowledge over the non-conceptual wisdom of our embodied process is perhaps misguided. I believe that the lessons of the primacy of touch is directly applicable to the foundation of design for Alzheimer’s patients. Alzheimer patients, due to the nature of the disease are already dependent on their haptic organs as the sole processing mechanism for interpreting the world.

the self by means of specialized parts of our enveloping membranes. All the senses, including vision, are extensions of the tactile senses”(Pallasmaa, 2009, p100). Pallasmaa argues that the essence of architectural experience lies in the existential experience.

We gain this through our haptic organs. The knowledge collected from our haptic senses provides us with the body memory that tells us who we are and how we are situates in the world. The primacy of touch is confirmed by the anthropologist and humanist Ashley Montagu, when he wrote: “The skin is the oldest and most sensitive of our organs, our first medium of communication, and our most efficient protector... Touch is the parent of our eyes, ears, nose, and mouth. It is the sense which became differentiated into the others, a fact that seems to be recognized in the age-old evaluation of touch as ‘the mother of the sense”(1971, p3). Although Pallasmaa is pleading only to the field of architecture and design to rethink the philosophical paths it has continued to take.

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Artifact 1: Materials and Form

Artifact 1: Materials and Form

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Figure 3

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Figure 2

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Artifact 1: Materials and Form

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Artifact 1: Materials and Form

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The Agency of Touch: Engaging Alzheimer’s Patients

Artifact 1: Materials and Form

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van Alphen, (a specialist of geriatric and alzheimer patients in Haarlem) she elaborated on specific stimulation which can trigger various existential experience for Alzheimer’s.

Safety and security are seen as positive stimuli, while threat and anxiety as negative.

Negative reactions can be evoked through momentary stimulus, while positive reactions needs longer ones. Van Alphen reveals that there is a hierarchical order among the sensory systems. This order is related to the development of the senses in a specific sequence and how information is represented, processed, and transformed (in faculties such as perception, language, memory, reasoning, and emotion) within nervous systems and brain. Consequently, this spans many levels of analysis, from low-level learning and decision mechanisms to high-level logic and planning. In the case of dementia patients, they are responding on the primary level of cerebral processing. Such as the “fight or flight” response (see glossary).

This is our most fundamental level of brain

The initial questions to begin my research were which materials were appealing for alzheimer’s patients? What characteristics of materiality will they most respond to? How will they respond to volume, texture, form, hardness? How will they hold the objects and explore with their hands? In essence, what type of haptic sensory input can become an effective trigger for them?

Alzheimer’s patients are living with the deteriorations of their brain functions, and thus their capacity for logic and intellectual thinking and communication are either hindered or completely gone. If primary stimulation and reactions are the basis for our existence. This is the primary mode of engagement that Alzheimer’s patients in the later stages are behaving through. When we are under threat or in harms way, we react differently. We react unconsciously. When we smell smoke we are restless and want to run away from fire. When you taste something bitter, it is often toxic or dangerous for you.

In my interview with physical therapist Astrid 134

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Artifact 1: Materials and Form

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The Agency of Touch: Engaging Alzheimer’s Patients

Artifact 1: Materials and Form

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I designed a tactile object in the form of a flower to test tactile curiosity and gaming engagement. The flower object was constructed with different combinations of materials and color in each of its parts (see Figure 2).

Velcro was integrated into the design to allow for every pedal and leaf to be plucked or adhere back. My approach was to test if the iconic form of a flower was registered by the patients and if they can engage in a familiar game of plucking the pedals off the flower one at a time. Engaging in this type of game is a good way to see the limitations of their cerebral processing capabilities.

process and the last to lose for Alzheimer’s patients. It functions primarily with the autonomic nervous system (reflex as well) that process information on a very primal level such as safety or danger. According to Van Alphen, due to the high sensitivity to stimulation in this area, patients are treated particularly with ‘soft’ noise, strong tactile stimuli, and soft lighting, avoiding strong bright flashing lights.

To test my initial questions of materiality and form, a collection of materials samples in various forms and density were presented. Multiple tactics were presented to distill the preference for certain size, shape or material characteristics. Objects were wrapped in the same material with differentiated forms in order to understand if there was a preference for certain iconic forms and if there was a relations to how the patients explored with their hands. I was interested in whether they explore with their fingertips only or willing to exert pressure or even deform the object. Furthermore, 136

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Artifact 1: Field Test Analysis

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Field Test Analysis

The Agency of Touch: Engaging Alzheimer’s Patients

Artifact 1: Field Test Conclusions

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Field Test Conclusions

Among the samples and artifacts presented to the patients, the most appealing to their sense of touch were hand size fluffy objects and silicon gel based objects that they can hold in the palm of their hands and explore with their fingertips. Pad size and button size silicon gel material sustained the longest contact (see Figure 3). The size of the surface area indicated an intuitive method of pressure exertion. The larger silicon gel pad were engaged with the palm or fist while the button size gels were often pressed or pinched with their fingers. One noted surprising reaction came from a woman who automatically picked up a material sample and touched her face with it. The act came without solicitation from neither myself nor the professional caretakers. For me this was exciting news. It indicated that the patient had tactile curiosity.

The flower object was more engaging to female patient than male. The game element was not successful among stage three patients. The tasks of constructing from parts to a whole was too high of a concept. Almost every patient engaged with their fingertips. Only one patient attempted to smell the flower. What I can conclude from the first field tests are: 1) The silicon-gel objects were most engaging due to the various tactile properties combined. It was appealing due to its

smooth surface, colorful gem like quality and its consistency.

The material was soft and firm at the same time.

You can apply force to it and make a fingerprint impression

on its surface. Given a few seconds, the memory quality of

the object regains its initial form. Thus the patient were

able to witness its own impact on the object and repeat it.

On the thermal level, the silicon retains the heat of the

user’s hand thus making it warmer and more comfortable as the

time goes by.

2) The fingertips were the most used to explore objects.

3) Bright and cheerful colors are definitely an effective

parameter for engagement.

> These insights propelled me to my next artifact and

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the concept of the ‘Space Extender’.

The Agency of Touch: Engaging Alzheimer’s Patients

Hierachies of Senses

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The Agency of Touch: Engaging Alzheimer’s Patients

Hierachies of Senses

Jack S. C. Chen

Hierarchy of Senses feeling together” (Goddard, 2005). The balance mechanism acts as a kind of compass in the body that continuously monitors the other systems, by which we obtain the feeling of where we are in space. Until we know where we are, we can not feel safe or have accurate spatial judgments.

Immediately after the sense of balance, is the sense of touch. Feeling information is developed to confirm the balance system in the child’s discovery of the environment. The next system to develop is the auditory and the last our visual system.

The role of the visual system of learning is so essential that it seems strange to place them at the end of the developing sequence. Our eyes work from the vestibular area to the brains. They share the same cranial (skull) nerve with our ears. Our sense of touch is deeply connected with the vestibular system as well, through the movement of hair cells (receptors) in the upper layer of the skin. If motion is the first language of the child, then the second sensation. Only

In order to understand better the possible existential experience Alzheimer’s patients can have, it is necessary to briefly discuss the developing sequence of the senses and their collaborative workings in the context of how the body perceives.

The first sense that develops is the sense of balance (vestibular system). It is vitally important for posture, movement, orientation, also for the sense of time, locomotion, and the estimation of depth. All other stimuli pass through the balance mechanism, at the level of the brainstem before they passed on to highly developed, specialized parts of the brain. Hence all the senses that the child needs to learn is in direct contact with the vestibular system.

Sally Goddard, the author of A Teacher’s Window Into the Child’s Mind (2005) writes about the role of the primary reflexes in our lives: “A newborn baby is not aware of the fact that sound and movement, sight and touch are different things. All impressions melt it in a single experience or 140

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Hierachies of Senses

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Hierachies of Senses

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less of the logical natural order of the word.

For example, if the word fo-ne-boutique was heard and the left ear was used for the first syllable and the right ear for the last two, it can reach the brains sounding as ‘netiekfo’ or even ‘nefotiek’. Inconsistencies in spelling, such as reversing letters, syllables and words, are a logical consequence. Goddard further points out that losing the ability to hear a whole frequency range of 125-8000 Hz can be problematic. Each language has a particular frequency band in which all sounds are in that language. If there is a hearing loss at frequencies, there are a number of sounds (b and d, p, and q), which are difficult to distinguish. This can cause spelling problems and/or dyslexia. Internationally known otolaryngologist, and inventor Alfred A. Tomatis has researched on the affect of high and low frequencies. He concluded that high-frequency sound is “energy enhancing” while low-frequency noise is often relaxing or “weakening”. Tests on a number of hyperactive children can be observed

when movement and sensation are sufficiently integrated, higher language-related skills such as speaking, reading and writing can be freely developed. Goddard brings an example of children who lack proprioceptive (see glossary) input must constantly move around in order to know their place in space.

They rely on the information from the muscle movements as compensation for the stimuli need to synchronize motion with sensation.

We can learn from this to understand how Alzheimer’s patient might feel and respond.

As their proprioceptive input is lacking, they have strong urges to move and walk or even rock in their seat.

Similar to the vestibular sensation and touch, hearing is also based on transfer of energy through movement and vibration. Right or left dominance of the ear can cause many problems. If a child changes ear preference while listening or speaking a word, the sound processed by the left ear, and a fraction later processed by the right will perceive the sound in that order regard142

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The Agency of Touch: Engaging Alzheimer’s Patients

Artifact 2: The Space Extender

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Artifact 2: The Space Extender

to revealed that they are hypersensitive in the high-frequency sound fields, sometimes even sounds between 2000-6000 Hz. (Goddard 2005). In the designs for the world of Alzheimer’s, these insights can be put to use to speculate on what scenarios and existential experiences are possible and applicable.

This in my opinion is a far better starting point.

The concept of the space extender was inspired from the body movements of Tai-Chi (chinese martial art). It aims to extend the patient’s space of interaction and comfort zone. As the disease becomes more severe the patients become ever more inward focused. Their engagement can be only about a foot away from their body. By enticing the patients to extend their hands outward and explore their surroundings, they are in fact increasing both their spatial awareness and space physically and psychologically. Just a few inches of extension, and the person sitting closest to them can be included in their sphere of recognition. Even minute distances of mere centimeters can make a world of difference in their awareness and engagement of their constructed world to include the smell or heat of the objects/persons near them.

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Artifact 2: The Space Extender

Inspired from this concept, I made a prototype for a large table surface out of colorful translucent soft urethane material called ‘Soft Gem’ (see Figure 4). The choice of material was derived from the conclusions of the first artifacts. The soft and colorful interface provide an attractive visual and tactile landscape for the user to explore with their fingers. Embedded underneath the tactile interface are pressure sensors, light sensors, and LED lights linked with an

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Figure 4

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Figure 5

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Artifact 2: The Space Extender

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Artifact 2: The Space Extender

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The Agency of Touch: Engaging Alzheimer’s Patients

Artifact 2: Construction

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Construction The technologies making up the Space Extender consist primarily of the following elements (see figure 5).

Arduino processor, waveshield and speakers. This construction made it possible to integrated a musical game where users can explore tactility with sound together with their loved ones or alone by themselves.

The tactics of the space extender is to integrate tactility, sound and light into the interaction in combination with applying a certain level gradient of difficulty to trigger the sounds to entice them to explore outwards.

This artifact was intended to test if interaction with the combination of sound and touch will sustain a longer engagement with the patients. Providing multiple sensory inputs would widen the opportunities for patient to engage on the combinations of the three senses. My aim was to test whether this combination will be of interest for the users (both patient and family members) to gain real existential experience and see if both parties are interacting with each other as well as with the artifact.

Main Processor: Arduino Uno Board. An Arduino board serves as a real- time time processor that registers the analog input triggered by various sensors and convert it to a digital signal that is map to a corresponding sounds file to be played out.

Sensors: Embedded under the silicon-gel interface are pressure sensors, light sensors and a potential meter. These sensor register the analog input such as pressure from the fingertips and send the signal to the Arduino.

Sound system: Wave Shield & Portable Speakers.

A wave shield embed into the Arduino board presented a good solution to minimize the total thickness of the interface. This wave shield allows for a wave bank to be stored 148

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Artifact 2: Field Test Analysis

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Field Test Analysis and played. The shield had a output jack allowing connections to portable mini speaker.

The space extender was field tested with some very promising results.

Patients reacted well to the object. One patient who had lost the ability to speak began to babble and his eyes were very active. You can tell by his shoulders and facial expression that he was more relaxed.

The care experts expressed that these small movements meant a great deal and they were very pleased.

Light:

RGB LED light strips were used to give the interface a soft white glow and possible dynamic color change dependent on the interaction.

Sound:

Sound files were engineered to create smooth transitions when multiple sensors were triggered. The choice of sounds ranged from sounds of nature such as soothing waves,falling rain, ambient tones, to familiar sounds of trains, railroad track, wind chimes, leaves rustling in the wind.

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Artifact 2: Field Test Conclusions

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The Agency of Touch: Engaging Alzheimer’s Patients

Artifact 2: Field Test Conclusions

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Field Test Conclusions Now that I was successful in extending the patient’s space through the combination of sound, tactile interface and light interaction. My next question was how to make them interact with a person. Since my original inspiration came from wanting to help family members connect better with Alzheimer’s patient. The reaction of bare-skin contact witnessed before inspired my next artifact: The Touch-O-Tone.

As I am not a computer-scientist but an architect, I am not able to discuss on a deep technical level about the field of interaction design. I applied the computerscientistand theorist Paul Dourish’s theories to my research. Let me first discuss Dourish’sdefinition and ideas of embodiment to discuss the term ‘embodied interaction’.

In order to put that term in perspective I must dive into the the quotidian definition of embodiment in phenomenology. I will attempt in the broad strokes to clarify only the relevant position of phenomenology in relation to Dourish’s view point.

On the basis of my observation I concluded that: 1) The initial feedback from the first contact with the object is

critical. It sets the association and logic of the artifact

for the user. If the sound and trigger relation has a delay

the users were not as keen to explore on their own.

2) Furthermore, the sensitivity of the trigger should be

sensitive to light finger brushes closest to the user to get

them hooked into exploring more.

3) Color and soft lighting was appealing to the patient.

One positive surprise in terms of interaction came from the assistance of caretakers. Some of the pressure sensors needed more pressure to set if off. To aid the patient, the caretakers placed their hand over the patient’s to help them. This bare skin contact was welcomed by both parties.

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Embodied Interaction

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Embodied Interaction

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Embodied Interaction as a Design Genre social understanding into the design of the interaction itself. Anthropological and sociological approaches are used to uncovering mechanism through which people organize their activities. By incorporating information about other people and their activities, interaction with computers can be enhanced. In Dourish’s view, tangible and social computing share their move towards a better fit in understanding and interaction in everyday human activity.

Within interaction design, several forces have coincided in the last few years to fuel the emergence of a new field of inquiry, which I summarize under the label of embodied interaction. The term was introduced to the HCI (Human Computer Interaction) community by Paul Dourish (2001) as a way to combine the then-distinct perspectives of tangible interaction (Ullmer & Ishii, 2001) and social computing. Briefly, his point was that computing must be approached as twice embodied: in the physical/material sense and in the sense of social fabrics and practices. The term Tangible Interaction (see glossary) encompasses user interfaces and interaction approaches that emphasize tangibility and materiality of the interface, physical embodiment of data, whole-body interaction, and the embedding of the interface and the users’ interaction in real spaces and contexts. Social computing entails incorporating 154

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‘Embodiment’ in Phenomenology

‘Embodiment’ in Phenomenolgy

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Martin Heidegger. Heidegger is the major figure associated with twentieth-century phenomenology, but his work is based on a rejection of one of Husserl’s basic premises.

This is the doctrine of Cartesian dualism – the idea, descended from Descartes, of the separation of mind and body. Husserl’s form of phenomenology explored the inner mental phenomena by which sensory impressions could be interpreted and meaning assigned to them. Heidegger rejected this idea. He argued that rather than assigning meaning to the world as we perceive it, we act in a world that is already filled with meaning.

The world has meaning in how it is physically organized in relationship to our physical abilities, and in how it reflects a history of social practice. For Heidegger, the primary question is not “how do we assign meaning to our perceptions of the world?” but rather, “how does the meaning of the world reveal itself to us through our actions within it?”(Dourish 2001). One way we encounter the world is to be able to use what

Phenomenology, as a philosophical position, was originally developed by the mathematician Edmund Husserl. Husserl was concerned with what he saw as a “crisis” in science, in which it was becoming increasingly distant from practical human concerns. (Dourish 2001) The field of science and mathematics was becoming too abstract. Husserl envisioned a science that was firmly grounded on the phenomena of experience. This philosophy of the phenomena of experience was Phenomenology.

Phenomenology set out to explore how people experience the world and how we progress from sense-impressions of the world to understandings and meanings. Fundamentally, it put primary emphasis on the everyday experience of people living and acting in the world and our mental experiences.

Husserl’s phenomenology was developed and revised by his student the philosopher 156

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point to the fact that meaning, for us, arises from the ways in which we engage with and act within the world. His definition goes beyond the physical presence, but includes the participation in the world, in real-time, real-space. So, physical objects are certainly embodied, but so are conversations and actions. They are embodied phenomena because their structure and orderliness derives from the way in which they are enacted by participants in real-time and under the immediate constraints of the environment in which they unfold. To this end, an embodied interaction is the creation, manipulation, and sharing of meaning through engaged interaction with artifacts.

we find in order to accomplish our goals.

The tools or instruments in the world disappear from our cognition when we use them to accomplish a goal: the goal is our focus and the tool a means, a ready to hand. The world occurs as an unconscious but accessible background to our activity. The most important feature of how we encounter the world, from Heidegger’s point of view, is that we encounter it practically. We encounter the world as a place within which we act.

It is through our actions in the world and how we engage with it to solve problems that the meaning that the world has for us is revealed. For Heidegger, action precedes theory; the way we act in the world is logically prior to the way we understand it. (Dourish 2001) Dourish defines ‘embodiment’ from the base of Heidegger’s logic. He values two facets of Heidegger’s proposal. The first is the primacy of action in the world, and second is the central importance of meaning in Heidegger’s analysis. Taken together, these 158

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Artifact 3: The Touch–O–Tone

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Artifact 3: The Touch-O-Tone

My research questions: 1) Can touch be an agent to help patients engage more with the

The aim of the Touch-O-Tone (see Figure 6) is to generate human to human interaction by creating a musical game when two people have physical bare-skin contact. This is a game played where one hand has contact with the artifact while the other hand touches the other person. The artifact detects the body current flowing through a closed circuit once the bare-skin contact is made. The current is amplified into sound. In this way the body skin becomes the musical interface. This concept (see figure 7) revolves around questions about what constitutes for an engaging experience in an ‘embodied’ interaction. I would like to reiterate two main points for this particular artifact’s contribution to engaging experience: connecting touch to audio with the right balance between direct and emergent responsivity, and justifying bare skin contact between patients to patients, or patients to caretak-

world around them?

2) Can it enlarge or reverse the direction of their own field of

engagement from introvert to extrovert?

3) Can the act of touch or ‘touching’ be an agent to connect

better with not only each other but with caretakers and loved

ones?

4) Given the social/cultural barriers that are related to touch,

can a design object crack these barriers to give different

opportunities to engage Alzheimer’s patients with the world

around them?

It seems intuitive to seek for design tactics that would manifest the Dourishian challenge of combining physical and social embodiment.

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Artifact 3: The Touch–O–Tone

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ers. Moreover, three experiential qualities are suggested as analytical tools pertaining to engaging experience in embodied interaction: the duality of performative immersion, performative social play, and the explorative nature of emergent meaning making.

Figure 6 Figure 7

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Artifact 3: Construction

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Artifact 3: Construction

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Construction The technologies making up the Touch-O-Tone consist primarily of the following elements.

Main Processor: Arduino Uno Board & mini mac An Arduino board serves as a real-time time processor, which senses the amount of conductive current flowing once the close circuit is made between the two users. The mini-mac runs the pure-data software which converts the current intensity into sound.

Sensors: Conductive foam and stainless steel plates were used as contact points for the palm of the hand to make contact. Conductive foam was the choice due to a lower threshold for conductive property compared to stainless steel. This allow for a more refine distinction between hard and soft touches. Other conductive materials were investigated such as graphite power mixed with toner binding agent. This was applied onto fabric through silkscreen processes. The conductive results yield well.

However, the substrate once dried is not sustainable due to its brittle nature.

Sound system: Portable Speakers.

Speakers were connected to the mini- mac to amplified the sound quality translated by the pure-data software.

Sound: Sound files were engineered to be mapped to the intensity of the conductivity. Five sound files were applied to make a distinction between soft touch, hard touch, short touches, and long touches.

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Artifact 3: Behavioral Design

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Behavioral Design As well as an abrupt touch and release. The quality of the sounds were engineered to give a ambient soundscape. Inferring to a sense of “aura” or “energy”. The longer the touch the more complex the layering effect takes place. Percussion sounds were introduced as a second layer to make the engagement more interesting. Urging the user to be more active and playful.

Much of the effort in designing the Touch-O-Tone technology has gone into its interactive behavior, since I assume that a straightforward coupling between touch sensor and sound would allow the users to “figure out” the causality too fast and leave little room for play. The aim of the technical work is to create a platform for a rich and interactive experience, and to this end I compensate the simplicity of the sensor by working with time and variance.

I compute the amount of what I call ‘energy’ as a way to capture the temporal aspect of the interaction: More touch and longer touches increase the energy slowly, where as the energy falls off at a faster rate when no touch is senses. This simple transformation opens up possibilities to modulate output by changing touch over time or sustain a certain level of ‘energy’ by tapping at an appropriate rhythm. The two parameters of energy over time and real-time touch are used to mix and match the different sound palates.

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Field Test Analysis (patient & caretakers) ations by stages due to the different ways the artifacts were useful for each stage.

The field tests of the Touch-O-Tone bear many surprising insight. The aim of the test was to find out if the novel idea of combining human touch and sound will bring a closer interaction between Alzheimer’s patients and caretakers. Open questions as to what sort of embodied interaction exists between these two groups and what other possibilities are there? On the spatial level, how will they perform with or around this artifact?

What type of configurations are desirable when sitting with multiple people around with wheelchairs? A group of 6 Alzheimer’s patients ranging in severity between stage one through three were introduced one by one to the artifact with two care professional to interact with. The context of the meetings space were held in a calm quiet ‘sneuzlen ruimte’ or sensory room where therapy of the sense were held for patients. I will summarize the conclusions and consider168

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Artifact 3: Stage Two Users

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Stage Two Users

Stage One Users Users in stage two were less active. They were able to place their hands on their own onto the conductive contact pads. However, it took much encouragement to get them to make contact voluntarily with the care professionals. A surprising response by one patient to move along with the percussive beat made everyone joyful with laughter. This prompted a care professional to grab one hand of the patient and swing it high and low as to actuate the sound effects. She created a fictional correlation movement and sound. In reality the sustained touch created the complex rhythm and soundscape that they heard. The improvisation lead to a discovery that helped sustained the engagement with the patients and to motivate more expressivity.

Users in stage two were less active. They were able to place their hands on their own onto the conductive contact pads. However, it took much encouragement to get them to make contact voluntarily with the care professionals. A surprising response by one patient to move along with the percussive beat made everyone joyful with laughter. This prompted a care professional to grab one hand of the patient and swing it high and low as to actuate the sound effects. She created a fictional correlation movement and sound. In reality the sustained touch created the complex rhythm and soundscape that they heard. The improvisation lead to a discovery that helped sustained the engagement with the patients and to motivate more expressivity.

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Artifact 3: Stage Three Users

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Stage Three Users

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Artifact 3: Care Professional Feedback

Care Professional Feedback

Users in stage three were least active. Care professional had to manually place their hand on the contact surface and demonstrate how it worked. Patients were searching with their eyes looking for the sound source. It was hard for them to understand the concept of touch to sound.

Although they responded well to the touch.

The lack of color scheme on the prototype did not help to attract their attention. Instead the patients were either looking for other stimulations around the room or looking down. Only short instants of engagements were successful due to the improvisation of the care professionals to place both of the patient’s hands on separate touch surfaces to create the closed circuit. Then touching the patients in multiple ways as to play their skin as an instrument. The patients were in a static pose but their eyes and facial expression followed the touches that landed on them.

Jack S. C. Chen

The care professionals were very enthusiastic over the Touch-O-Tone. Three major points from their own caretaker-user perspective emerged while playing. First was the lack of variation in types of sound or instruments. They wish for a wider palate much like a keyboard due to the preference of each patient. Second was the lack of control over the introduction of the rhythm. They wish for a manual control in which to manipulate the rhythm when they see fit to sustain the patient’s engagement.

The existing program introduced a percussion rhythm after five continuous seconds of touching. However, the skin contact must remain for the rhythm to sustain. Third is the placement of the contact region. They wish for a wider region and more spread out. This would solve the natural placement of hands or the entire arm. Often the patients do not have the ability to flatten their palms. The use of wider regions of contact can take this into account.

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most appreciated. Stage two and three patients and family members welcomed the experience due to the fact that the patients were not able to speak. The prototype created a new activity was very much appreciated. All family members did not have any hesitation to touch their loved ones. Even in the presence of strangers. The Touch-OTone’s impact on stage two and three are the highest. Patients were clearly drawn out of their own inwardness and engaging with the family member and the interface.

In regards to ergonomics, interaction is often with two to three persons. Family members often remark the device would be inviting when their daughter brought their grand children along. Thus, the sitting for three or more would need to be considered in the design. Other design considerations stems from the sitting configurations with wheelchairs. The seating distance needed to achieve more intimate contact and to facilitate constant contact with the table and the other person. I observed family members

The Touch-O Tone was introduced to family members and patients to test if it was interesting for the family members.

I wanted to know if the social barriers of touch could be overcome. In regards to ergonomics, I wanted to find out in what sitting positions they would touch each other and the type of space they would inhabit with their movements. Finding these answers gave direction to the interaction design of the software and the physical object.

For all three stage, the prototype was a very welcomed experience. For stage one patients and their family members, the immersion into play was clearly apparent.

Both parties were very actively trying to create and play with the soundscape. They were truly listening to the music and shown a very active presence. The complexity of the sound design would be for this stage 174

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often placing the bare-skin contact hand in multiple places to test. However, that hand would rest in place while busy with the other hand moving along the surface of the contact pad. The conductive foam pad’s surface gave pleasant sensations due to its texture.

This seem surprisingly to me, as I would assume that the bare-skin contact hand would be the one moving more. I can only postulate that they were right-handers and due to the sitting position was naturally inclined to touch the patient with the left hand. Her more dominant right hand was making the contact with the table. Righthand or left hand considerations also play into the intuitive positioning of the body (see Figure 8).

Figure 8

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Artifact 3: Field Test Conclusions

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Artifact 3: Field Test Conclusions

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Field Test Conclusions In conclusion to the findings of the field test, the Touch-O-Tone can be said to mean different things for different stages of Alzheimer’s disease. Among the three stages represented by the patients, we can discuss the interactive qualities and its applicable tactics for embodied interactions the Touch-O-Tone provide under three experimental qualities. The first is performative immersion. The second is transformative social play. The third is meaning making.

of social norms when the play stops. This experience of inside and outside can intensify the engagement experience. Especially when the patient is more active and able to explore the complexity of the soundscape they themselves are creating. The stage two and three Alzheimer’s patients occupy a bubble of their own world already. They require a different tactic for engagement.

Transformative social play As seen from stage one patients’ interactions with caretakers, the social norm for touching can be side stepped by the use of transformative social play. That is to say the leader of the interaction should set an atmosphere of playfulness to offset the inherent hesitation for bare skin contact. This element of improvisation is essential for stage one patients to be set an ease to explore. For stage two and three patients the social norm barrier of touch is less impinging. However, the social play is important for stage two and three as a way to open up

Performative Immersion Performative immersion takes place mostly with stage one patients. The interaction between the patient and care professionals is not dominant in either way.

The focus of the interaction jumps between the immersion in play and becoming more comfortable in touching each other. Stage one patients are more aware of the social norms of touching. Thus they are able to experience the immersion bubble outside the social norm while playing and the realities 178

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the sound and aura or color of LED lights to mood can allow different interpretations of the movements and touches. In the field test, it was apparent that the improvisation of the caretaker to motivate the patient to move in greater gestures, by making an association between the height of the raised arm to the pitch of the sound. However untrue the association was, it was effective. The social play freed the expressivity of both parties.

different directions of motivations. Such as reacting to the soundscape in unexpected movements or expressions to motivate more interaction. With stage two and three the quality or complexity of the soundscape is not tot focus or motivation for exploration.

In fact the reactions to the touch and sound from the caretakers and the patients are the main motivator for further interaction.

Meaning Making In combination with transformative social play and performative immersion, meaning making completes the trinity of experimental qualities that lead into what Dourish defines as embodied interaction. To reiterate his definitions, an embodied interaction is the creation, manipulation, and sharing of meaning through engaged interaction with artifacts. Meaning making by method of creating an interpretive framing as a narrative backdrop for new experiences to emerge is also a good tactic for sustained engagement. For example, making a link between 180

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Figure 9

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Figure 10

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Mapping Sound Touch and Movement

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Workshop Methodology A simple methodology of filling in a matrix (See figure 10 for sample of matrix) via a discussion circle was implemented to flush out the 4 questions revealing the relationships between touch, sound and movement for Alzheimer’s patients.The following questions were:

One of the main questions in the technology design of the Touch-O-Tone was which sounds should be mapped with which kind of touch and movement. To this end, I set up a workshop inviting experts in the field of touch, sound, and movement. Physical therapist, occupational therapist, psychomotor therapist, music therapist, speech therapist, tactile designers, sound artist, and architects were all invited to discuss and map out the relations between sound, touch, and movement for Alzheimer’s patients (see figure 9)

1) Which Sound evokes which calming or stimulating behavior

for Alzheimer’s? (Sound vs Behavior)

2) Which types of physical interaction is applied to alzheimer’s

patients? (Movement vs Behavior)

3) What types of Touch constitutes a certain intent? (Movement/

Touch vs intent)

4) Movement vs Sound Quality

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Workshop Conclusions that the human heartbeat is the sole basic sound in which we ground ourselves. In his therapy practice, he applied the idea of selfdetermined territory onto physical space as the first step to ground oneself and center ones body and mind. This practice leads to a secure and trusted space in which the person can become more extraverted and in synch with their own heartbeat. In conclusion, regarding which type of sounds is appropriate is too subjective for the end user.

What I can go on is that low frequency relaxes while high frequency excites. Rhythm is an important element to ground the patient and to inspire them to move physically.

Sounds used should be recognizable as affected by touch and movement to give a coherent impact. And one last thing that is of note to write about is the idea of incorporating negative sound that would also discourage negative behavior within the design parameters for interaction.

The conclusion to the workshop was not entirely successful. The group found it difficult to offer personal interpretations of generic sounds to match types of touch.

What was concrete and useful were some consensus of using movement as the leading denominator to create a systems approach to engineering sound to touch. For instance, consensus was made to identify 6 types of touch used on patients. They are: Kneading, padding, stroking, grabbing, Tickling, and holding. We then evaluated each types of touch with 4 distinct characteristic parameters: direction, intensity, duration, velocity. These characteristics can be easily mapped to quality of sounds. If we are to talk about sounds, we can certainly describe it by velocity, frequency, pitch, and period. Using this as a guideline, I can create systems of sounds to match the types of touch within certain themes. Themes like sounds of nature where pure sounds of water or birds, or Such or daily sounds, or body sounds. As speech therapist Maurice Willem suggested 186

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Conclusions: Artifacts, Qualities and Design Direction

Mapping Sound Touch and Movement

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caretakers. The concept of social play applied within the interaction created a bubble in which hierarchy and social norms could be sidestepped. This bubble transformed the space into a safe and leveled playing field resulting in greater freedom of improvisation and self expression.

The contribution through my research process produced three artifact level elements that proved to encourage and sustain engagement for Alzheimer’s patients. The first is connect touch and audio with the right balance between direct and emergent responsivity. The second is justifying the bare-skin touch between strangers, and the third is connecting touch with light. These three elements are able to engage with Alzheimer’s patients in stages one through three. Furthermore, three suggested experimental qualities can be used to unpack the notion of engaging experience in embodied interaction: the duality of performative immersion, the transformative quality

The aim of this research was to understand if touch can be an agent to help patients engage more with the world around them. Given the social/cultural barriers that are related to touch, I analyzed if a design object can crack these barriers, afford different opportunities to engage Alzheimer’s patients and connect to them, thus enhancing their well-being.

Through my ‘research-through-explorative-design’ process, I was able to distill artifacts and qualities that proved to have a desirable effect on the sustained engagement for alzheimer’s patients. Furthermore, I applied the concept of ‘embodied interaction’ defined by Paul Dourish to test possible behavioral interactions between patients and caretakers and family-relatives. These interactions gave insights into possible tactics in which emergent meaning making can take place between patients, family members and 188

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The concept of the Space Extender can be applied in the field of physical therapy, where a design object in the form of a tree is standing in an open space. Sound is produced by way of contact, deformation or applied pressure of the trunk and branches.

The tree made out of soft huggable material can swing one way or the other. The user being temped to stretch and reach for branches must exert, walk, stand, stretch their limbs to explore the effects. Such creative objects can be useful to motivate elderly to move and sustain their well-being.

In complimentary to my written thesis and research I have designed an object called ‘making the temporary last’. This object is the next generation of artifact that combines the insights learned from previous artifacts. The ‘Making the temporary last’ integrates the concept of the Space Extender and the Touch-O-Tone together into a table configuration that allows multiple patients in wheelchairs to interact with each other and family members. The main logic in combin-

of social play, and the explorative nature of emergent meaning-making.

To conclude, there is another question begging to be addressed: How would the concepts of both the Space Extender and Touch-O-Tone be translated and applied to different realizations? It seems fair to envision this concept to be applicable to interior space of nursing homes where Alzheimer’s patients who need professional care reside. Like ubiquitous computing or integrated design, where the technologies are embedded in everyday objects, the concept (or application) can happen everywhere. It can be integrated into the corridor walls linking public space to private space. It can be the dining table where almost everyone will spend an hour or two every day, or countertop of the kitchen island. Better yet, it can be built into the wheelchair in which the patients who are sitting on it all day long, will have every opportunity to use it whenever there is someone around.

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Artifact 4: Making the Temporary Last

Artifact 4: Making the Temporary Last

ing the two concepts is to sustain value of the objects for the Alzheimer’s patients as they regrettably progress from stage to stage. The table has different meanings and usages from stage to stage. Regardless of the stage, the object will create opportunities for engagement and embodied interaction. Finally, I would like to point out that the level of the engagement engendered by the Touch-O-Tone concept indicates that it could have potential to transform certain social settings by provoking the questioning of prevalent social norms. Such a deployment would be more akin to critical design, through which I hope to explore its implications further in the future.

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Artifact 4: Making the Temporary Last

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The Agency of Touch: Engaging Alzheimer’s Patients

‘Making the Temporary Last’ is an interactive installation in the form of a table to encourage affective bare-skin touching.

This installation was developed to allow the family members and caretakers of Alzheimer’s patients to engage the patients using the sense of touch as the agent. It creates opportunities for newly shared experiences beyond speech.

The table made out of raw carbon fiber, mdf and arduino technologies are able to sense the body current of the users when they are in contact with each other. Furthermore, different types of affective touch such as holding, stroking, tapping, grabbing, kneading can be differentated and translated to different types of sounds that match the motion and emotional intent of the gesture.

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Section: Leg Construction

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Artifact 4: Making the Temporary Last

Details: Table Top Construction

Steel rectangle frame connecting steel legs. The frame will be hidden by mdf Following design geometry.

Steel rod welded to steel Tear Drop shaped plate for Stability. Rod to be threaded Wood or foam casing.

Steel rectangle frame connecting steel legs. The frame will be hidden by mdf Following design geometry.

Steel rod welded to steel Tear Drop shaped plate for Stability. Rod to be threaded Wood or foam casing.

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Materials: The sides are carbon Fiber weave (140mm). This material is chosen for its high conductivty and tacile quality.

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MDF Panel For Table Top: There is a slight relief milled out.

White Color in photo is primer.

Desire two coats of spray paintwith a gradient pattern over the entire surface.

Color: Pantone Solid Process.

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The Agency of Touch: Engaging Alzheimer’s Patients

Appendix

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Appendix Alzheimer’s Disease (Symptoms) Alzheimer’s disease generally leads to impairment of cognitive and memory function, communication problems, personality changes, erratic behavior, dependence and loss of control over bodily functions. Alzheimer’s disease doesn’t affect every person the same way, but symptoms normally progress in 4 stages. On average, people live for 8 to 10 years after diagnosis, but this terminal disease can last for as long as 20 years.

Stage 1 (Mild): This stage can last from 2 to 4 years. Early in the illness, those with Alzheimer’s tend to be less energetic and spontaneous. They exhibit minor memory loss and mood swings, and are slow to learn and react. They may become withdrawn, avoid people and new places and prefer the familiar. Individuals become confused, have difficulty organizing and planning, get lost easily and exercise poor judgment. They may have difficulty performing routine tasks, and have trouble

2300 mm

2300 mm

Plan: Table Top

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com­municating and understanding written material. If the person is employed, memory loss may begin to affect job performance.

They can become angry and frustrated.

Appendix

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trol, they may become depressed, irritable and restless or apathetic and withdrawn.

They may experience sleep disturbances and have more trouble eating, grooming and dressing.

Stage 4 (Severe): This stage may last 1 to 3 years. During this final stage, people may lose the ability to feed themselves, speak, recognize people and control bodily functions, such as swallowing or bowel and bladder control. Their memory worsens and may become almost non-existent. They will sleep often and grunting or moaning can be common. Constant care is typically necessary. In a weakened physical state, patients may become vulnerable to other illnesses, skin infections, and respiratory problems, particularly when they are unable to move around.

Stage 2-3 (Moderate): This is generally the longest stage and can last 2 to 10 years. In this stage, the person with Alzheimer’s is clearly becoming disabled. Individuals can still perform simple tasks independently, but may need assistance with more complicated activities. They forget recent events and their personal history, and become more disoriented and disconnected from reality.

Memories of the distant past may be confused with the present, and affect the person’s ability to comprehend the current situation, date and time. They may have trouble recognizing familiar people. Speech problems arise and understanding, reading and writing are more difficult, and the individual may invent words. They may no longer be safe alone and can wander. As Alzheimer’s patients become aware of this loss of con202

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Glossary

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The Agency of Touch: Engaging Alzheimer’s Patients

Glossary

Jack S. C. Chen

Glossary Haptic

Relating to the sense of touch in all forms.

Ubiquitous

Proprioception Perception of the position, state and movement of the body and

computing

(ubicomp) is a post-desktop model of humancomputer interaction

in which information processing has been thoroughly integrated

vestibular sensations.

limbs in space. Including cutaneous, kinaesthetic and

into everyday objects and activities. In the course of ordinary

Vestibular

Pertaining to the perception of balance, acceleration and

activities, someone “using” ubiquitous computing engages many

deceleration. Information obtained from semi-circular canals in

computational devices and systems simultaneously, and may not

the inner ear.

necessarily even be aware that they are doing so. This model

Kinaesthesia

The sensation of movement of the body and limb.

is usually considered an advancement from the desktop paradigm.

Relating to sensations originating in muscle, tendons and

More formally, ubiquitous computing is defined as “machines that

joints.

fit the human environment instead of forcing humans to enter

Cutaneous

Pertaining to the skin itself or the skin as a sense organ.

theirs.”

Includes sensation of pressure, temperature and pain.

Tactile

Pertaining to the cutaneous sense, but more specifically the

‘Fight or Flight’

sensation of pressure (from mechanoreceptors) rather than

Response

The “fight or flight response” is our body’s primitive,

temperature (thermoceptors) or pain.

automatic, inborn response that prepares the body to “fight” or

Force Feedback Relating to the mechanical production of information sensed by

“flee” from perceived attack, harm or threat to our survival.

the human kinaesthetic system. Devices provide cutaneous and

When our fight or flight response is activated,sequences of nerve

kinaes thetic feedback that usually correlates to the

cell firing occur and chemicals like adrenaline, noradrenaline

visual display.

and cortisol are released into our bloodstream. These patterns

of nerve cell firing and chemical release cause our body to un

Human Computer Interaction

(HCI) involves the study, planning, and design of the

dergo a series of very dramatic changes. Our respiratory rate

interaction between people (users) and computers. It is often

increases. Blood is shunted away from our digestive tract and

regarded as the intersection of computer science, behavioral

directed into our muscles and limbs, which require extra energy

sciences, design and several other fields of study. The term was

and fuel for running and fighting. When our fight or flight system

coined by Card, Moran, and Newell in their germinal book,

is activated, we tend to perceive everything in our environment

“The Psychology of Human-Computer Interaction”. The term

as a possible threat to our survival. By its very nature, the

connotes that, unlike other tools with only limited uses (such

fight or flight system bypasses our rationa mind—where our more

as a hammer, useful for driving nails, but not much else),

well thought out beliefs exist—and moves us into “attack” mode.

a computer has many affor dances for use and this takes place in

a sort of open-ended dialog.

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Alzheimer’s Disease TRANSIT Community

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Invisibilis Radialis Sensorum

Ricky van Broekhoven

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Jack S. C. Chen

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Jack S. C. Chen

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Call for Suffering

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A Temporary Room and the System of Comfort

Chanida Lumthaweepaisal

p 304

AIWEN

A Temporary Room and the System of Comfort

Chanida Lumthaweepaisal

p 304

AEKKALAK

A Temporary Room and the System of Comfort

Chanida Lumthaweepaisal

p 304

LIESBET

A Temporary Room and the System of Comfort

Chanida Lumthaweepaisal

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FILARDHI

From Alzheimerbus to Lijn#3210

Naomi Cheung San

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From Alzheimerbus to Lijn#3210

Naomi Cheung San

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Call for Suffering The Suffering Through Space

Introduction

Wenqian Luo

Call for Suffering The suffering through space One year ago, when I was doing my education project, I encountered a story from the book Road to Heaven: Encounters with Chinese Hermits (2009) by Bill Porter.

It is about a Chinese hermit who lives in mountains alone, out of touch, cultivating grains and vegetables for food, staying in a chamber with leaking roof, chill and damp.

They explained about their life. ‘Up before dawn to chant sutras, song of the bell at night, three vegetarian meals a day, a room, a bed,a mosquito net, no bill. When my legs get too sore or my mind too restless for the meditation cushion, I read.’ (Road to Heaven: Encounters with Chinese Hermits , 2009, p.3) Even though, hermit life sounds out of date, they are not out of the season. The sort of suffering environment helps them to

Call for Suffering The Suffering Through Space

1.

Chinese Hermit ‘Road to Heaven: Encounters with Chinese Hermits’(2009) 2.

High mountains, Chinese ink painting

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avoid unnecessary desire, and to focus on their own thinking. The physical suf fering for the Chinese hermits is a way to higher consciousness.

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The Suffering for Me

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The Suffering for Me

Space context Spatial diagram: The suffering for me(Based on feelings)

Loneliness

Isolation

Conflict

Exposure

Despair

Pressure 1 1.

Loneliness Despair 2.

Confusion

Block

Hesitance

3.

Block Interruption

Confusion

2

Misundersatanding Interruption

Mistake 3

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The Suffering for Me

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The Suffering for Me

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Spatial study Triangle

Triangle with mirror

Out of scale

Out of function

Triangle with square

Spatial diagram: The suffering for me (Based on spatial rules)

1.

Triangle space 2.

Triangle space with mirrors

Not in a line

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The Suffering for Me

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3.

Triangle space with square inside 4.

Glass maze 5.

Out of function 6.

Scale maze

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The Suffering for Others

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The Suffering for Others

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Spatial study Cave like space: The process of walking in cave like space is beautiful, while feeling curious and keeping expecting. The crucial experience of the entire journey is density — you fear, you expect and you are confronting yourself through the space.

Spatial research: The suffering for others(Based on individual interview)

Emptiness: Emptiness doesn’t mean ‘nothing’. But it could mean having nowhere to hide, nothing to expose, nowhere to be.

Emptiness is a space without borders but with a territory.

Claustrophobic space: Everyone has a certain fear for confined space, which gives them the feeling of being locked in, being alone and being in darkness. The sort of space has a common character – it is completely closed off, with artificial lighting or without any light, it is sound-proof and empty.

Out of place: Generally speaking, out of place is the feeling that you lose the communication with space and you cannot understand the surrounding by experiencing it.

1.

Emptiness

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2.

Cave like space 3.

Out of space

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The Suffering Concept

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The Suffering Concept

Concept The suffering try-out: initial idea: fragile, collapsing, out of balance, tensive space

1.

Out of balance 2.

Collapsing tensive

1 Cave like space: Unknown quantity, unexpected happening Emptiness: Without out borders Claustrophobic space: Confined space

3.

Fragile collapsing

Out of space: Lost communication with space

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3

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Call for Suffering

The Suffering in Place

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Call for Suffering

1. floorplan

Rietveld academie

2. facade grid 3. site photo

bridge

workshop room 1

Rietveld Academie: Glass pavilion Area: 48 m2 Function: small exhibition space, temporary workshop space

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Call for Suffering

The Suffering Design

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Call for Suffering

Proposal 1 1. site model/1:100 2.

Use strategy blocking facade to create confined space.4 pieces of panel( according to facade grid) form the second facade.

3.

Second facade transform into different shapes.

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4. space sculpture 5.

Space atmosphere

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Proposal 2

Call for Suffering

Proposal 3 One entire piece of facade, transforming into an entire space form. It can transform in a small territory, but with less possibilities.

1 1.

Blocked focade mode

Split the panel into three pieces in both side. (so it is six pieces in total) Each two piecesin both side (mirroring position) are connected by rolling wheels on top.

Space becomes unstable, interactivily collapsing, flexiblily open and close.

2.

Focade transform 3.

Inner space 2

The Suffering Design

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The Suffering Design

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Call for Suffering

Pattern study It comes to the last option since the option has the most possibilities to transform, even from facade into floor.

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The Suffering Design

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Call for Suffering

The Suffering Design

Real try-out 1.

Lifted mode 2.

Half collapsing 3.

Into floor collapsing

1 Based on weighting system, one movement can cause the unbalancing state.

That is the collapsing moment comes from.

When people need to get into the space, need to play with the blocked facade, to cause the space shrinking.

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The Suffering Experience

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Exhibition 6.

Different ways of changing the state.(pull/ push/drag/ hold)

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Overview 2.

Outside view 3.

Inside view

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Transforming shape 5.

Forming different space

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Exhibition Forming various of space.

See more on: www.wenqianluo. tumblr.com

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Thesis Introduction

Master of Interior Architecture Sandberg Instituut

Call for suffering The Suffering Through Space

Thesis

Thesis Introduction

Master of Interior Architecture Sandberg Instituut

cal space – that is how we perceive space in personal ways. The suffering through space is very much related to people’s person experiences as long as suffering is a personal term. So the main question for me in thisthesis is to know how people suffer though space and how do they perceive that.

My research is based on exploring people’s personal experiences. In the course of working on my thesis I set up a public call for participating in my research project.

I spread the call (see Appendix) for people who would be willing to share their suffering experiences with me. Altogether I discussed my main questions with 8 people based on their own experiences of suffer- ing though a certain space. By interviewing people and translating their personal experience into spatial intervention, I developed a typology of spatial language describing and taking together those experiences gathered through my interviews. Further more, I added my own experiences of suffering that are analysed in my thesis. I want to thank all the

I believe people need suffering.

The suffering is about facing fear and flaw, facing painfulness and sadness, or even facing death. It deals with exploring the way in which fear, sadness, loneliness and power are all interrelated. In a way this kind of suffering is a process of self- educating.

I am interested in creating experiences of suffering through space that is different and that would deal with these kinds of issues, but not in a torturous way or a dark way. But instead in a way that has a sort of lightness and beauty to it.

There is also an inner space that we feel. This inner space contains feelings, stories, memo- ries, imaginations and illusions. It is our emotions that build up our inner space. This space is like a theatre – it changes as the emotion changes, it is empty but fulfilled with a variety of settings. The inner space of our mind reflects on the physi268

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Thesis Chapter 1

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Chapter 1: Why do we need suffering?

Luxury poverty

people who got involved in my research, who participated in my interviews, who commented my work and who inspired me.

Are you familiar with this moment: suddenly you can’t focus, your mind goes everywhere but nowhere. You feel anxiety, trying to change the spot again and again.

By facing the window view you try to calm down. But it does not work. There is something wrong with the place – it could be the height of the table, the angle of the sunlight, or the whisper from the papers.

You feel like maybe you need more water or have to go to the toilet. Perhaps you should get some inspiration from the Internet. Oh, wait. There is a book can help...

We care about our demand, and we translate this demand into getting something. For ex- ample, we feel that we can not move on, we need to get inspired from the outside world, we believe the help from others or the internet, we are tending to get something. But we are not caring for our own thinking, we care too much what we 270

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be a virtual space that you expect, or an illusionary space that you thought you were in.

can get, even though it might not be that helpful. There is a type of luxury poverty.

The luxury is not about getting something, it is about what you can lose. Reducing is more difficult than achieving. Do we ever give ourselves a certain time for thinking, only thinking? You can not get anything easily, you can not rely on the outside. All you can do is rely on yourself. By reducing our demand we feel a certain kind of ‘suffering’, but this ‘suffering’ is not suffering at all. This ‘suffering’ is staying lonely, staying thinking, and staying doing.

This suffering is for instance sitting quietly in a small room, and doing nothing else but think- ing. Our mind also needs space in order to indicate where to go. By limiting the space for your mind, it will calm down, take time to be patient, and go into deep thinking. You could stay in a huge space, but you only need a small space for your mind. That space is one of the right scale and atmosphere. That space is the inner space. It could be abstract, it could 272

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Feeling dangerously Some people choose to travel. The writer Jack Kerouac said about his travels ‘You could call my life on the road. Prior to that I’d always dreamed of it’(Kerouac, 1976). The long jour- ney, especially in tropical countries, turns out to be a way of enduring hotness, exhaustion, sickness, dizzy, stomach pain, sunburn, sleepless, small cabin space, bump driving. But they keep silent about this, with no complaint.

As the road is moving on, the scene turns out to be an infinite field of maize under glaring sunshine, flowing water in the river, denseness of the jungle, lotus flower from the mud water, mango trees, grass shelter, drinking dog along the river bank, hot and broad sky, burning field. It is dangerous but simple. They do not com- plain because they choose it and they know the danger and the beauty.

Some people choose to stay in the big city, having good occupations and decent social life. They satisfy themselves by the given comfort and convenience. They

are ruled by their desire and ambition, trying to prove their value by substance, to get rid of vacuity. They spend a lot of money in restaurants or bars, and search for fun in parties. They try to evade from thinking and loneliness, never searching the real self.

They have lost the possibility of feeling dan- gerously.

Feeling dangerously, means to dare to search for the real self, it is a kind of passion having nothing to do with the result.

It is like walking in the wind, you know you can’t grasp any- thing, but you know your choice.

Feeling dangerously also means dare to face failure. When the whole process becomes ex- treme without hesitating and retreating, the only way is like ropewalking, straight forward and no backwards. You could lose, but you could never stop learning from that. It is more about how you deal with the failing feeling and how to make them work for better being. Likewise, Artist Courtesy Elmgreen& Dragset said, ‘Our 274

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The ruins works are about failures. I love failures.

They are so useful. Success smoothes the ground. Failures make you consider new things from new perspectives’ (Article Try again fail again fail better, Frame#57 JUL/ AUG 2007, Page 93) Feeling dangerously is close to the beauty of walking on thin ice. You have to pay close atten- tion to the walking process, when the normal movement becomes much more difficult than you expected. You can really feel that your foot is stepping into uncertain ground, you feel not sure, but you have never felt so clearly about walking.

The tension of the space is crucial when you suddenly realize that you have to know the space more by trying to feel safe.

What make the ruins so touching and emotional are the memories that they are affiliated to. Even though the scene already turns out to be abandoned, lost in time, not functional, even scary, the trace of life is still left over, attracting people to go into, to wonder. The decay is suf- fering and beautiful.

‘There is such a beauty in ruins, such a stillness, and magic for the imagination.’

(In Ruins, 1997, PAGE 2)

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‘I came on a great house in the middle of the night, Its open lighted doorway and its windows all alight, And all my friends were there and made me welcome too; But I woke in an old ruin that the winds howled through; And when I pay attention I must out and walk Among the dogs and horses that understand my talk, 0 what of that, 0 what of that, What is there left to say?

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‘The series “The beauty of ruins” began with a fortuitous trip to an old abandoned hospital.

Neither I knew at that time what awaits me there, nor I knew at that time what awaits me there, nor I knew at that time that I would get so trapped by this theme and that it would grow to such an extent. But despite all the places have their own charm – the results from the different age and use, and also from the circumstances of leaving out –they have still much in common. You can feel that there once people lived and worked. Their hints, however, disappear every day more and more. Either they are the victim of planned new uses or the nature is doing its part to the decline.’

(In Ruins, 1997, PAGE 3)

Jörg Rüger, Photographer (http://www.sichtbarkeiten.de/the-beauty-of- ruins/,2011)

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Chapter 2: Cave-like space

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One of my interviewees told me his experience in cave like space: ‘I was once in the Cuchi tunnel, a tunnel system which was built during the Vietnam War to defend against the enemy.

The system contains several different small cham- bers to trap the enemy. The tunnel is narrow, just for one person to pass through.

I was there with a group of travellers. The whole group was stuck because of one girl felt scared of climbing over a pond. I was in the underneath of the tunnel, a tiny and dark space, could not move, and had no way to escape. The endless darkness made the whole experience unpleasant. It was a c ertain sort of fear and insecurity. They tried to persuade her to move on, to face the situation, and consider how the others were feel-ing. The whole conversation made me feel even more anxious. I had no idea that when I can get out.’ (Interview 1) This experience differs from the meditation training that I described earlier, although both of them contain a condition of

There is a famous hypnotherapy treatment that allows you to see your preexistence. The doctor will let you lie down, relax your whole body and take a deep breath.

After that he will describe an experience to help you sink deep into your subconscious: you are entering into a cave like space, which is dark, endless and suffocating. You turn out to be there, moving on, searching for the light. Your pace expresses your hesitation, but you believe that if you go through the cave, you will find what you expect. Do cave like spaces have something to do with rewarding? If you fear darkness, the unknown and breathlessness, why should you go on for nothing?

On the other hand, the process is beautiful, while feeling curious and keeping expecting. The crucial experience of the entire journey is density — you fear, you expect and you are confronting yourself through the space.

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stillness. As a part of the hypnosis experience I receive energy, balance, concentration and a kind of happiness. It is a feeling of receiving a present, instead of being unpleasant like the experience of the tunnel that is described in the interview.

‘If compared with to my experience of staying in jungles, confronting unknown situ- ation circumstances, and wild animals, the later one is terrifying but has embracive power from the nature. This kind of suffering is not suffering — it is back to the real position of human, retraining ourselves to stay aware of the surrounding. I prefer this type of experience more than the one in cave. It is also unsure about what is going to happen and what you will encounter. However this is the way that I feel more comfort- able about.’

(Interview 1) Since the cave like space, which contains elements like darkness, the unknown and breathless- ness, I wonder how the feeling of the space will change if I create a different type of cave like space

Thesis Chapter 1

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changing some of the elements. For instance, it could be a white tunnel with lighting, but with a long way to its exit.

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Call for suffering The Suffering Through Space

Thesis Chapter 3

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Chapter 3: Emptiness Emptiness doesn’t mean ‘nothing’.

But it could mean having nowhere to hide, nothing to expose, nowhere to be. Emptiness is a space without borders but with a territory.

‘Once I had a dream that I woke up in North Alaska. It was a cold winter day.

The sky was totally dark. The place where I stayed was the house in which I grew up.

Every- thing was the same. But I was beaten by a kind of emptiness feeling. There was nothing outside – no light, no human, no trace. It was lonely, and afraid — afraid of having nothing to do, afraid of just slowly dying.’

‘Darkness means emptiness for me, but whiteness means openness.’ ‘If I could choose, I would go there for an adventure, but not alone. I am not scared.

I believe I can survive there.’ (Interview 2) How will you imagine the emptiness of space? Will it be a white cube in a gallery; will it be a cell-like room in a prison; or an infinite plain outdoor space?

As a kid, I was once in an apartment of my mother’s friend. I was alone in the living room. It was a shallow, dark, and silent space with the TV’s sound. A feeling of emptiness pervades me. It came from my loneliness — it looked like no one would stay in this room, crudeness — window view into a leaking wall with water dropping, the quietness — the television sound was spreading the whole space without being listened. I felt a kind of melancholy from this emptiness.

On this moment I felt that space should embrace me rather than ignore me. The entire living room showed that it was not meant to stay. The dim lighting indicated that even the space existing but the function not for inhabiting. If all functions of this space are gone, the space is gone.

For example, I create one of spatial configuration for interpreting emptiness that contains four mirror walls, allowing the border to disappear in a limited size room.

When you enter such a room, you suddenly find yourself in an infinite space. It is a com284

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plex space with dif- ferent layers of mirroring but actually it consists of nothing besides four mirror walls. This suffering experience comes from losing our feeling of privacy and intimacy in space. Our privacy and intimacy are erased through the mirroring effect in space. The mirroring wall makes the whole space seem extending and private for the visitor. If other people enter the space, then privacy immediately disappears by exposing the former visitor to all the others in every side of the mirror wall. It means having nowhere to hide. The emptiness comes from space, but also from your mind. It takes away your perception about space.

On the other hand, emptiness can be interpreted in space with border but without territory. A spatial configuration is dividing the space by lines on the floor and I investigate how borders restrict the movement of people. Comparably, creating the same configuration but dividing space by glass walls to see how it works differently for people’ s movement with territories.

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Thesis Chapter 4

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Call for suffering The Suffering Through Space

Chapter 4: Claustrophobic space

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takes their place. We become part of this deserted set. Finding ourselves on a stage where the ac- tion suddenly begins without anyone having decided what the play is.

What role are we supposed to play? Which part have we been given? Observer, accomplice, perpetrator, victim? The surveillance cameras at the ends of the corridors purvey a sense of latent unease. We, as viewers, are also under observation. And we start to see ourselves from outside, keeping step with ourselves as it were. As soon as you close the small door in the fire door, at the start of the exhibition. You become your own guinea pig in an open-ended experiment.

A long, gleamingly bright corridor stretches out before you. The floor is pale and shiny, ceiling is sound-proofed with thick pyramidshaped insulation panels. Heavy, brownishred sliding doors with small viewing slots open into three small cells, side by side, with tall windows in the center of the far wall that you can’t see out of and that only allow a diffuse light to enter the space. No objects

Everyone has a certain fear for confined space, which gives them the feeling of being locked in, being alone and being in darkness. The sort of space has a common character – it is completely closed off, with artificial lighting or without any light, it is sound-proof and empty. The way to let people suffer is that there is nowhere to escape, nothing to look at and no one to talk to. You have to stay by your own with your own strength or being obligated to. It mostly applies to prison, to a concentrate room in mental health institute and meditation space.

An effectful claustrophobic space was created in the Weisse Folter, as an installation by the German artist Gregor Schneider. In the essay ‘The Challenge’ Brigitte Kölle described this spatial experience: ‘The absence of human beings means that the exhibition visitors as it were 288

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for the eye to rest on. The sliding door closes automatically, and you are alone...

The atmosphere of the rooms become increasingly leaden, the sound-proofing materials seem to close in on one, the claustrophobic effect that ensues from the physiological impact of the changed sound pressure on the eardrum becomes ever more oppressive.’ (Weisse Folter: Gregor Schneider,2007,p.41-42) Weisse Folter was an experimental art project that was related to prison space.

Schneider tried to implant the prison space into this exhibition in order to create the space with a quality of unexpected overwhelming unease. The whole experience emphasized the fear not of what was happening but of what could have happened, the fear of pushing open a door into a dark room when we neither knew how big that room was nor what was hidden within it.

Although it was a exhibition in the basement of K21 Museum in Düsseldorf, the claustro- phobic atmosphere was provoked by

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the forementioned quality and by the entrée limitation of one person.

Since the Weisse Folter project is more closed to experience that does not existi in daily life much, I come to one interview that expresses a more familiar experience for everyone. I call it ‘the contemporary daily suffering’.

‘I have been in sort of sauna room.

It is tight and humid. First ten minutes it is ok. Afterwards it scares me. It felt like there was nothing to breath, like the air is getting thick, almost out. It scares me that you cannot move, you cannot change the air quality, and you cannot get out. It doesn’t matter if I am with others or by myself. I think it is because it is very humid and breathing is hard. When humidity is high, you feel pressure. Being in a very dark, humid room, you feel it is closed in. I don’t really like to be in that space.’

‘However in a sauna situation, you have less fear, because you know the door is open. It is suffering in a certain way. You 290

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can change the level by sitting lower or higher. When you feel like you have an option, the suffering is less. When you are sitting in a room that you know you can get out and there is a feeling that you can move, everything is psychological. Of course physically you also feel that you cannot breath as much. Normally I stay there about 10-12 minute, just for testing how far I can go. You know you need to get your body heat to certain level to sweat. Usually people say that after you stay around 8 minutes, you should go out. But I just try to push a little bit more, to make sure that I can do it. Just to see where are my boundaries. It is not necessarily healthy. From the 8 minutes onwards you start to feel uncomfortable. You feel it is not that comfortable, but somehow at the end you will feel good. It is also sort of confrontation that through the suffering, at the end you will feel relieved. It is also a psychological sense that going through it is a good thing.’ (Interview 3)

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When we encounter the claustrophobic space in daily life, the first thing we think about is to get out, no matter how long it will take or how safe it is. Further more, the interviewee indicated that the air condition is important because of the oppressive feeling.

Although it is a space he feels uncomfortable to stay there longer than 8 minutes, he only chose to stay longer in order to test his own boundaries. It is about the quality in Claustrophobic space, it reaches your limit, it causes you to fear and go beyond your fear.

This is also what inspired me about my spatial intervention for claustrophobic space. I cre- ate a sort of cube space with translucent walls and a contrast of lightingoutside of the box is light and inside is dark.

Just to let people who go inside find it hard to express oneself and explore the feeling of being isolated. As the light contrast prevents people from being shown, the only way to get out of the room is to wait and to endure.

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1.

4538 KM,MDD Museum Dhont Dhaenens, Deurie 2006 2.

Weisse Folter: Gregor Schneider, K21 Museum in D端sseldorf, 2007 3.

Blind Light, installation

by Antony Gormley ,The Hayward Gallery, Southbank Centre, London ,August 2007

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1

3

4.

Diagram of design

4

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Chapter 5: Out of place was a bit big- ger so the proportion in between me and the space just broke up because I became really too big to use that space. The attic was with a shallow angle.

There was one period that I could stand there and felt intimacy. That was my little playground. After several years I felt that space was very compressed, narrow, dark and I could not move freely anymore. I totally lost that feeling. Sometimes I have the same feeling when I enter my wardrobe underneath of the staircase, which is very inefficient space. I think it also has to do with this fact that I do not feel in scale in relation to the rest of the space. For me a dark big space where everything is over dimension with really big openings. I think that would also disorientate me to a level in which I perceived suffering. It basically makes me out of place.’ ‘I think it has to do with dimension, either a small scale or a big scale. As long as there is no light for me to see the space, I feel lost. It also has to do with the sense of control. You seem like in that space, but you

Out of place, not in the proper position; disarranged; in a setting where one is or feels inap- propriate or incongruous.

It can be a space without a proper function, a space without right scale, a space without sufficient lighting, or a space without a clear orientation. Generally speaking, out of place is the feeling that you lose the communication with space and you can- not understand the surrounding by experiencing it.

There is an interview that shows better how this feeling takes place in daily life: ‘I had been living in Luxembourg in a house when I was really small, 5 or 6 years old. And I can remember that we had this attic that was really steep slope of the roof.

To me that space really felt compressed, really narrow. When I was really small kid I liked that space because I felt like I was embraced by it, and I felt that it is a safe shelter. But the thing is I had lived there until I was 9 or 10. When I came back to that space when I was a little older, I really disliked it. I felt totally uncomfortable there. I 296

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lost the connection with the space. That is out of place.’ (Interview 4) Based on this experience, I interpreted the spatial quality into cube space.

One is with spatial division by glass walls and the routing is to go through all the corridors in between glass walls that are either too wide or too tight to pass through. The out of space feeling will occur when you meet the space out of your scale unexpectedly.

The other one is with spatial division by different layers of walls with openings on them.

Some of the openings are with a function for passing while others are just fake openings not to be passed through. The basic idea is to implant the out of function into a space to impair visitors’ orientation, to enhance the out of place experience.

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Inspiring image from internet 2.

Diagram of design

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Conclusion When I talked to people by raising this question ‘Have you ever suffered from certain space?’, normally I got feedback after some hesitation. One person told me that he doubted whether this word ‘suffering’ was not too heavy to describe his experience.

I think the word is associat- ed with a sort of heavy feeling and it is personal. That is why I chose this notion as an object of my thesis: to know more about what happens when people encounter suffering in their daily life, what makes them fear, what encourages them to face their fears and what is the space like. I call this contemporary suffering experience though space 1919something that is present for everyone in his life, confronting him and questioning him.

When we talked about the suffering experience, it turned out to be mostly unpleasant expe- rience. Although it was not a place people would have liked to stay, some of them said they would try it again for an adventure or for testing their personal boundaries. It is the latent quality the suffer-

ing experience through space, which turns the process into a poetic and self-aware journey. That is what I intend to evoke, a questioning process, involving a certain controversy and self-educating.

When I dealt with others’ experiences and interpreted them into the spatial form, I found that it is important to emphasize the aesthetic quality in the suffering process and prolong the whole experience.

In order to receive criticism and comments from people, which will add to the discussion about whether it is positive. As a part of my project I plan to build a real scale installation in public space, which will be a 3 by 3 meter cube space containing the suffering quality and present what the suffering is in my contemporary context space.

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Call for “suffering�

I am from Sandberg Institute, Interior Architecture.

Credits: Special Thanks

Wenqian Luo

Project tutor:

Interview 1: Henri Snel, 45,

Femke Bijlsma

Architect, Professor at the

Henri Snel

Sandberg Institute, Inte-

Rinske Wessels

rior Architecture Department (from The Netherlands) April,

I am doing my graduation project which is about the suffering through space.

I am looking for people who would like to be interviewed.

Thesis tutor:

12th,2012 Interview

Margaret Tali

2: Ricky van Broekhoven, 28, Product designer, Student in

I am sure you would find the talk itself not suffering.

I am willing to tell you more about the topic if you are curious.

It will be a short talk in 20 minutes.

It will take place where you like.

It will inspire me in so many ways, so just be free to talk about your story.

Installation building up:

Sandberg Institute (from The

Mu-Chieh Chen

Netherlands April, 19th,2012

JinJing

Interview

Jack Shih-Chien Chen

3: Jack Shih-Chien Chen, 36,

Xiaoxiao Xu

Architect, Student in Sand-

Ting Gong

berg Institute (from The United

Da Wang

States) May, 15th,2012 Interview

My main question will be: Have you ever suffered in certain space?

How did you feel about it?

Exhibition cooperation:

4: Dennis Schuivens, 33,

Chanida Lumthaweepaisa

Architect, Student in Sandberg

Belle Phromchanya

Institute (from The Netherlands) May, 15th,2012

What is the most impressive part of the space make you feel

Interview

suffering?

5: Tom van Alst, 25, Architect,

Would you like to go back to that space again?

Student in Sandberg Institute

Why?

(from The Nether- lands) April, 19th,2012 Interview

If you want to share your experience with me,

6: Femke Bijlsma, Architect,

If you want to know more about my project,

teacher Architecture Department

If you are also dealing something similar with me,

at Gerrit Rietveld Academie,

If you just want to talk about your suffering, fear, isolation, etc

Amsterdam (from The Netherlands) April, 5th,2012

Please contact me. My name is Wenqian. You can send me message via

Interview

email cathenre@hotmail.com, or mobile 0684822362.

7: Reinier Suurenbroek, Architect, Rocksteady Design

Hope you will be interested in it!

(from The Netherlands) April, 5th,2012 Interview 8: Andrew, Psychologist (from The Netherlands) May,30th,2012

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Prologue

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A Temporary Room and the System of Comfort

A Corridor of student housing in Uilenstede, Amstelveen, 2012

The long silent corridor, as ordinary as it should The closed grey door, as ordinary as it could The tiny naked room, as ordinary as it would This is my room, a temporary one, as ordinary as you can imagine A Temporary Room and the System of Ccomfort is an investigation about comfort in small-scale temporary habitations, in which I study how one inhabits one’s private sphere under the condition of temporality and comforts oneself in an un-familiarised space. The aim of this research is to under­ stand how one constructs physical and psychological comforts under temporary and restricted spatial conditions. It explores different possibilities for presenting the construction of comfort, which cannot be 304

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Defining Comfort

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Defining Comfort represented by standard architectural drawings or photography.

Different individuals have very different ways of constructing comfort. It is not easy to quantify their personal comfort into levels or understand it through numbers.

Although comfort is not easy to measure, I believe that this research could raise and trigger the awareness on how we, interior architects, address the way of living and designing spaces.

Take a look around yourself. Have you ever questioned why your house is so ordinary – not in the decorative artefacts but in the raw aspect of the space itself. How comfortable is your house? These two questions operated as the premise for this thesis.

They involve significantly the subject of domestic sphere. This chapter discusses about the quality of life in the smallest section of societal dynamism – a home.

It concerns historical development of the notion of home and the way it influences our understanding of comfort.

We have been possessed by the ordinariness of the modern archetype and adopted it as a benchmark for our modest way of living and inhabiting the house. What is absent from here is the urge to question, how does the modernist paradigm manipulate the notion of home?

Ordinary things contain the deepest mysteries… the characteristics of modern housing appear to transcend our own culture, being lifted to the status of universal 306

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Privacy is not a major concern in domestic interiors prior to the modern period. Evans also discusses the role of the door in relation to domestic architecture.

Before the Renaissance, according to him a door was perceived as a form of space binding. The emphasis was placed on the association among occupants themselves and between occupants and spaces, not onto the division and disengagement of spaces, in contrast to today, when the door is a fundamental architectural element which functions as an evident separation (when closed) or connection (when open) between two adjacent spaces.

Evans demonstrates that during the Renaissance, the relationship between people was more intense compared to nowadays. The way houses were planned during the Renaissance represents that intensity.

Analysing the plan of Villa Madama in Rome, built in the sixteenth century, he shows that almost every room is interconnected through several openings. This spatial constellation

and timeless requisites for decent living… since everything ordinary seems at once neutral and indispensable (Evans, 1978, p. 56)

The British architect and historian Robin Evans, who theorises the meanings of space, perception and imagination in relation to architecture, examines the modern home differently. In his essay “Figures, Doors and Passages 1978” from Translations from Drawing to Building and Other Essays (2005), he analyses the implication of paintings and literatures to the domestic floor plans from the sixteenth century (the Renaissance) to the mid-nineteenth century (the modern period). His analysis is based on figures who appear in particular scenes of the selected images and texts, and the significance given to the space that surrounds those figures. Evans portrays a lucid thread of the evolution of privacy inside home during the modern period due to change in values related to people’s usage of space.

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of the villa strengthens the intimate relationship among individuals. ‘Thoroughfare rooms’ are convenient and encourage the act of exchange inside domestic spaces. It is a concept adopted from ancient Greek and Roman architecture.

Later, during the nineteenth century, this type of domesticity was seen as incommodious for its occupants and something that completely took away all privacy. Gradually privacy became as essential as convenience. “The change was important not only because it necessitated a rearrangement of the entire house, but also because it radically recast the pattern of domestic life.” (Evans, 1978, p. 64) Evans’s study shows that during the modern period the private aspect of domestic life became more distinctive. Privacy contains convenience, and the loss of privacy is perceived as inconvenience. During this time, ‘Terminal rooms’ became the most desired forms of habitation. As a consequence, another intervention into domestic-

Defining Comfort

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ity derived – the passage (or corridor). This new domestic component was designed in order to eliminate all unnecessary traffics between rooms. Instead of going through various spaces before reaching one’s destination, rooms became connected by one or more collective pathways. Thus, individual inhabitants could live their lives peacefully without disruption or redundant interaction with others in their terminal rooms.

Indeed, this development of privacy in domestic sphere sways the notion of home. These rooms promote individuality and yet simultaneously suggest neutrality as their basis. As privacy gradually became more significant in our social norms, we tended to abandon interaction and preferred to live life behind closed doors.

What ceases to have presence in the positivist house is the entire material culture deployed in the construction of the ego, any indication of an individualization of space, this being substituted by the authoritarian and fantasmagoric presence 310

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United’haitation de Marseille, Le Corbusier, 1947-1952

of another person who invisibly directs the norms of private conduct: the modern architect.

(Abalos, 2001, p. 81)

The Spanish architect Iñaki Abalos discusses in his book ‘The Good Life: A Guided Visit to the Houses of Modernity’ (2001) that the identity of person used to be ex-pressed through the material culture before the modern period. Demonstrating one’s taste and individuality in society was done through the way of life, including one’s home. This ceased with the emergence of the modernist architect. The role of the architect has implicitly influenced the way we live – through the implementation of a modern way of living.

Discussing the home of the modernist, it is sound to bring up the work of Le Corbusier. The image (1) is a scene of a single-family apartment block in Marseille designed by Le Corbusier. As an architect, designer, urbanist and writer Corbusier was one of the pioneers of modernism who irrefutably advanced the modern way of living.

The interior perspective illustrates the scene and situation determined by how the architect aspired for this space to be used and represented. The scene shows the flexibility of the space since few objects are attached to the walls, floor or ceiling, but are floating in the space, and the neutrality of the space that has been designed to suit every household. From this image one immediately senses the comfortable feeling and spatial suggestion indicated by natural light and arrangement of furniture.

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Looking at the image, I see no difference from my own situation, as an inhabitant in my temporary room: elements such as a huge window, plain walls, and a pot plant, plus some photographs that make this ordinary space more personal. Giving character to the space is one of many ways of constructing comfort. Home, nowadays, is still an ordinary private sphere and a place where we embrace ourselves with comfort.

The Argentinean designer and thinker Tomas Maldonado considers in his essay “The Idea of Comfort” (1991) comfort as a certain quality of life, which comes about in the modern age when home, privacy and comfort are synchronised. He refers to the idea of ‘livability’, meaning the services that a particular ambient reality can provide in terms of convenience, ease, or habitability. Livability does not refer to the elementary survival, e.g. hunger, deprivation, illness, violence and physical or moral compulsion on individuals but a set criterion for every habitation (Maldonado, 1991, p. 35).

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According to Maldonado, comfort is a modern idea. Before the Industrial Revolution, the need (or expectation) for comfort – in the sense indicated above of convenience, ease, and habitability – was the privilege of the few. (Maldonado, 1991, p. 35) In the same rhythm, together with ordinariness and neutrality, comfort becomes crucial and embedded in our standard of home.

There is a more optimistic than pessimistic sense attached to the word comfort. In the modern period, it evokes ease, well-being, cosiness, relaxation, pleasure, and content in the domestic sphere. All the positive physical states which were absented from majority of people during the period of the Industrial Revolution. Nowadays when comfort is a standard, some people might have a great demand for comfort in their home, while others might not. It depends not only on personal expectation and understanding of comfort but also economic situation. However, there is always a demand for comfort related to those optimistic realisations 314

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manifested in the modern period. Comfort conceals and reveals itself, deliberately and unintentionally, in our living environments – in interior ambience, in pieces of furniture, in daily consumption, and in every single object.

Home in the modern period from the introduction of privacy were later developed according to causes of efficiency and neutrality. As an interior architect, I cannot deny the advantage of neutrality that the modernist architects have set as a standard of home. When architecture is neutral enough there is always adequate space for personalisation. The personalised moment that people start to shift things around and position things inside their private spheres is when home and comfort are being created. The transformation of anonymous and ordinary space before it became one’s own space.

This is a temporary room with only one door, yet, the a comfortable one…

Home is a place where one lives, and a place for which one feels affection.

Home is a simple and straightforward form of space that triggers all kind of complex sentiments – fondness, intimacy, warmth, attachment, and comfort. What if home happens to be temporary? What if home happens to be small? What if home happens to have just you living on your own? Do you still consider it as a home? From my experience, I believe that temporary habitation with a short timespan affects the way people pay attention to and how much effort they put into the place. In this chapter I discuss the way personal objects are used for constructing comfort under temporary circumstances.

The sociologist Liz Kenyon, who has studied the meaning of home for students, describes it in the context of students’ transitional experience of home. The transitional period is from childhood home (depen316

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dent dwelling) to university dormitory (independent dwelling). …for a dwelling or social unit to become a real and meaningful home it had to provide for and reflect a number of key elements. Home was seen to exist at four crucial levels: as a personal, a temporal, a social and a physical space. …The nature of the academic year, with students residing in student accommodation for only around nine months per annum… meant that this was not viewed as a stable or permanent home.

(Kenyon, 1999, p. 86, 89)

A Temporary Room and the System of Comfort

Student housing complex in Uilenstede, Amstelveen, image from Bing maps 2012

In her article ‘A Home from Home’ (1999), Kenyon divides the meaning of home into four categories: the personal, temporal, social and physical home. In my opinion, even though these four subject matters are related to home, they cannot however be clearly defined from a spatial point of view. The definition of a temporary home in Kenyon’s research is an unstable and impermanent place although it has the potential to be familiar and lasting. It has a different con-

Temporary Room and the Function of Objects

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cern compared to the meaning of temporality that I use in my thesis.

In the framework of this research, a temporary home refers to a temporary place where inhabitants stay for a short period of time (five to six months). The notion of temporality is significant as it determines the level of affection concerning the place and its inhabitants, as well as the construction of comfort inside the room. This will be elaborated through the interviews in the following chapter.

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Examining comfort in the temporary habitations, I situated my research in one of the student housing in Amstelveen. The selected student housing in Uilenstede, Amsterlveen met the criteria of the framework that I set: temporality of housing, smallscale type of the room, and interior monologue of the inhabitant. The building consists of ninety-one student rooms where one lives temporarily in a room of one’s own. Each student resides in a furnished room of 12 m2 with share kitchen and bathroom facilities.

I previously used to live in a family house with a separate bedroom, bathroom, living room, study room, dining room, kitchen and garden. I considered the room where most of activities, e.g. dining, relaxing, working, and sleeping, take place in one single space, a ‘small-scale type’ habitation. I will show that in such a place, objects are material agencies that are used for constructing comfort.

The construction of comfort in permanent and temporary habitation is

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different. In the state of temporality, objects play a more important role in creating comfort than in a permanent situation. When we stay in our permanent home, the place has comfort in both physical and psychological senses. In the permanent home, all the self and family’s accumulated objects form familiar scenes, and sense of belonging. We are so used to the place, and to everything being under control and stable. Stability and familiarity comfort us. But when we are about to leave home, we think about how to cope with the new space, and what kind of things we will be able to have in the new place. Is the place comfortable enough to live in? We cannot carry the entire home with us. We carry the minimum amount of objects when we travel. At that moment we have to make decisions about the part of home we would like to carry with us to make those temporary places as comfortable as our own home.

On the basis of my observations, I divided the objects inside the rooms that I analysed into four different categories.

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Filling the Space with Objects Inside the temporary room, the placement of objects influences the behaviour of the inhabitant. And in turn, the behaviour of the inhabitant influences the placement of objects. Those objects respond to my concept of representation of comfort.

The placement of objects is significant for this investigation, as I assumed; the decision made for the placement of those objects are related to temporality, authority inside the space, and expectation of comfort. They inform us whether the position of objects is accidentally fixed or determinedly fixed. This is important in order to find out the relationship between objects and space that represents the construction of comfort.

People arrange homes in their own specific ways. Flexibility of space is valued as the freedom to create one’s home, and it seems to be something that one always has. Or is it what one really has? At the moment we move into a new place, the notion of home is not yet created. No one falls for that anonymous space. Feelings of home and comfort are ambiguous before one gets used to the space; both of those feelings are different for each person.

The first thing we do is try to arrange and organise the space with furniture; this is the opportunity to create our own home, the first rendering of our anonymous space before we fill the space with objects and mutate it. After one familiarises oneself with the space, those feelings become more obvious.

This chapter discusses objects and their meaning in temporary living environments.

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categories: provided objects, personal objects, daily consumable objects and new objects. The novel Hotel du Lac (1984) about the feeling of attachment to temporary space, theories about domestic objects and existing situation research data in conjunction with interviews are used to conceptualise the understanding of objects in relation to the construction of comfort in temporary space.

She started to fold and pack the dresses she would no longer were here, and, as the process gathered momentum, her almost precipitous bundling together of shoes, books, scent bottles, until all that remained of her life at the Hotel du Lac was her nightgown, her hairbrush, and the clothes she was wearing. Then, having nothing more to do in this room, which was once more impersonal, ready to receive the next guest…

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of home in student housing, since it illustrates the feeling of detachment and attachment inside one small temporary space occupied by one person. The author, Anita Brookner, raises the issue about the personal and impersonal when Edith, the character in the described scene, tries to pack her personal belongings and prepares to leave the hotel. After a certain length of stay, she feels affection and is attached to the room. A hotel room is a place where personal and impersonal spaces are juxtaposed, in a way it is similar to a temporary student room. It is true that people claim their existence by leaving their personal belongings or marks. Once the marks have been taken away, the place again becomes anonymous and devoid of one’s identity.

The novel reminds me of a quotation “to live means to leave traces.” (Benjamin, 1978, p. 155) Its author, the German philosopher Walter Benjamin in his book “Reflections” (1978) criticises the bourgeois interior. According to him, domestic furniture

(Brookner, 1984, p. 172)

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has set the value of bourgeois existence, the home of bourgeois is a place where one realised one’s delusive individuality. The same accent was placed onto the family symbolisation of bourgeois interior by Jean Baudrillard, the French philosopher, theorist and sociologist, whose works often associated with post-modernism speculation.

“The typical bourgeois interior is patriarchal… The emphasis is on unifunctionality, immovability, imposing presence and hierarchical labelling.” (Baudrillard, 2005, p. 13) In his book The System of Objects (2005) he discusses the transformation of the functions, forms and gestures of domestic furniture from the traditional environment to the modern environment. Before the modern period, the way furniture filled in the space affected the total environment of home as a representation of family’s taste.

I translate this to the context of my research, a temporary student room (A plan is understood to be drawn at about 1200 mm vertical position above the floor. It shows the rela-

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tionship between spaces and other physical objects from above. In this research, there are 5 layers of specific vertical positions: 400, 650, 1000, 1650, and 2500 mm.), and argue that “to live means to construct comforts.” It is because furniture has changed its function to not only relate to one’s identity but also to relate to well-being.

It guides me to another study about home, objects, and identity of post-modern domesticity. The Meaning of Things: Domestic symbols and the self (2002) is a study of eighty-two families in contemporary urbanised America during the 1970s and 1980s, undertaken by Mihaly Csikszentmihalyi and Eugene Rochberg-Halton. Their study aims to find out how and why people relate to things in their immediate home setting, after the influence of the modernist paradigm. It illustrates several remarks about domestic objects and their intimate relation to persons, which will be cited and considered later on.

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… home contains the most special objects: those that were selected by the person to attend to regularly or to have close at hand, that create permanence in the intimate life of a person, and therefore that are most involved in making up his or her identity.

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Inventory provided for students in the selected units (Information from DUWO Student Housing Corporation)

(Csikszentmihalyi and Rochberg-Halton, 2002, p. 17)

When discussing home in the context of temporary student housing, it is important to keep in mind that the spatial possibilities in student rooms are restricted by the provided inventory. Usually these include a single bed, wardrobe, multi-purpose table, table chair, easy chair, small refrigerator, and bookcase which the provider considers as the fundamental elements of a temporary home for students.

With the inventory, a temporary room that has already presented itself as an anonymous space is again forced to become more anonymous by those fixed elements.

I perceived it as contradictory to the perspective of home mentioned in the quotation above.

Filling the Space with Objects

Inventory list for (address) Name tenant Room number Room type Dutch mobile number

: : : : :

Chanida Lumthaweepaisal

Uilenstede Eenheid |4 – 16 | 38 – 50 | 18 – 32 | 72 – 86 | 88 - 98 ______________________________________________________________________________ ______________________________________________________________________________ 04D-H, room with shared facilities ______________________________________________________________________________

[ [ [ [

] ] ] ]

2 1 1 1

entrance unit/salto + room key balcony key [if present] bike shed key postbox key

[ [ [ [ [ [

] ] ] ] ] ]

1 1 1 1 1 1

wardrobe table desk chair easy chair book case refrigerator

[ [ [ [

] ] ] ]

1 1 1 1

[ [ [ [

] ] ] ]

1 1 1 1

bed mattress mattress cover mattress protection cover(under normal cover) continental quilt quilt cover pillow pillow case

[]1 []1 []1

waste paper basket desk lamp wall lamp

[]1 []1

box with kitchen utensils television with remote and coax cable

[ ] 1 or 2 [ ] 1 or 2

curtain(per meter) curtain rail(per meter) Communal inventory

[ [ [ [ [ [

] ] ] ] ] ]

1 1 1 1 2 2

washing machine cooker dish rack dining table hanging lamp toilet brush

Complaint report: _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Stichting DUWO will do its utmost to solve all reported above within two weeks. Urgent matters: please contact the service number at: +31 (0)20 3429666.

I declare that upon taking possession of the rented accommodation all the items mentioned on this inventory list are present in good, clean and working order.

I realize that at the end of the rental period, all the listed items have to be in the rented accommodation in good, clean and working order.

I accept that I will be charged for any items damaged, no longer working, missing or made dirty.

Thus agreed and signed in duplicate, Date

: ___________________________________________________________________________________________

Name tenant

: ___________________________________________________________________________________________

Signature tenant : ___________________________________________________________________________________________ THIS FORM ALWAYS NEEDS TO BE RETURNED WITHIN 5 DAYS TO THE DUWO OFFICE IN AMSTELVEEN, UILENSTEDE 108.

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Apart from the furniture and the room itself, all students whose rooms I have studied have things that they carried from their homes. In this case, an object has an important function in transforming the feeling of detachment to attachment. The specific layers of the room reveal in detail how different individuals have different ways of dealing with objects inside their rooms.

The drawings (1-5) show the research technique. All drawings were made to scale from the observation of existing situations of four temporary student rooms.

On the basis of my observation, I formulated four categories of objects inside student rooms: provided objects, personal objects, daily consumable objects, and new objects. 1) A provided object is an object that was provided by the student housing corporation as a standard for a furnishedroom type 2) A personal object is an object that a student carried from his or her former habitation or home 3) A daily consumable object is an object on which students expend

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and dissipate or finish, e.g. food, toilet paper, and medicine. And 4) A new object is an object that a student bought or brought in after he or she had moved into the place.

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I understand these objects are material agencies. They are used in my analysis to comprehend the way students fill in their rooms, cultivate their own identities and make those anonymous spaces comfortable enough to live in.

From the conclusion of the study about the most cherished objects in the home, carried out by the interview question: what are the things in your home which are special to you? (Csikszentmihalyi and Rochberg-Halton, 2002, p. 56). It shows that people acknowledge domestic furniture as a symbol of comfort since the modern period.

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is powerless and does not aim to show off one’s prodigality or identity. It only aims to provide necessary and compulsory comfort, which might compensate for the feeling of instability about the place.

According to my interviews with four students, most students do not put much effort into making the place feel like their real home because of the anonymity of the space and the short period of time.

Some responses to the questions “What is home for you? And does it feel like home staying in this room?” make it evident that the student housing is meant to be so temporary that no affection for the space is needed. For them, home is tied to a psychological meaning: “Home is the place that you spend your time with your family… I even don’t feel like staying in this country [the Netherlands], how can I feel this place [temporary room] is my home? This place cannot be my home unless I find someone really close, probably one day.” Aiwen

Not surprisingly, chairs, sofas, and tables are most often mentioned as being special objects in the home. One could say that furniture is special because it makes life at home comfortable...

(Csikszentmihalyi and Rochberg-Halton, 2002, p. 59)

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requirements. It is convenient enough for me to live within these 6 months.” Aekkalak

“This room is a temporary home not home. This room can be home if it is not temporary. The sense of belonging for this room is the feeling that this is the only place that I can stay. I have nowhere else to go.” Aekkalak

However, not everyone has no affection for the room. Two students from my interviewees respond differently to the same questions: “Home is a place where you go to feel at peace… this [temporary room] is a place where I can shut everything out for a while and be on my own, it does feel like home here” Liesbet

Aiwen considers relationships and connections with intimate persons to be more important than material things, which is why her room cannot be her home unless she finds someone to cherish the time together in that space. For Aekkalak, stability is the essential issue concerning home. He has no affection for the room for the reason that it cannot provide him with stability, in a psychological sense. It is just a temporary place for him to stay. From his response, one can presume that the condition of the room does not affect the way he constructs his comfort.

“Home is a really nice place to live… this [temporary room] is a very comfortable place to live and my floor mates are very friendly to me. Even though my room is not so beautiful, as long as the people are nice, I like it.” Filardhi For Liesbet, the feeling of home concerns her privacy. For Filardhi, the relationships with others support the home feeling, and the condition of the room is

“The provided furniture in this [temporary] room is already sufficient for my basic 340

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secondary. It is clear for both that the feeling of home is not dependent on time and condition of the room, but immediate and adjacent physical environments that the room could offer.

“This room is a temporary home not home. This room can be home if it is not temporary. The sense of belonging for this room is the feeling that this is the only place that I can stay. I have nowhere else to go.” Aekkalak

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“I just rearrange the furniture into the right place, convenience for my habit, and things are not blocking each other, also not blocking the way. Then I place my things into the shelf and wardrobe. Nothing much.” Aekkalak “The first day when I arrived, I have very small stuff carried with me. I did not change much of the positions of furniture except I swop the bookcase with side table, and that is all.” Filardhi

Nevertheless, the way in which students inhabit their rooms can convey the construction of comfort. The first thing that they did when they first moved into their rooms was rearrange the positions of the furniture to suit their habits and requirements and then they filled the space with their personal objects:

Comfort not only builds up from the total feeling of home in the room but also the value of objects recognised by individuals.

According to Csikszentmihalyi and Rochberg-Halton the relationship between body and furniture are also important.

Furniture is the product of psychic activity. It takes the concentrated attention of many people to acquire the raw material and the intention to fashion it in a shape that conforms to human body and its actions.

“I immediately rearrange the furniture and bring everything out from my travel bag.” Liesbet 342

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When positing questions related to comfort in the course of my interviews most of the respondents associated the question with physical comfort (the feeling of well being brought about by internal and environmental conditions that are experienced as agreeable and associated with contentment and satisfaction). Furniture is the most often mentioned object concerning comfort. It is not furniture of one’s own that is bought after one moves in, but the provided furniture. Furniture was also related to self-satisfaction. There are some instantaneous links between physical comfort and bed among several responses:

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“Comfort, for me, refers to a place that when I feel tired, I can go there and then relax. It is here, on my bed.” Liesbet “First of all I need to clean, and change the bed sheet. For such a small room, cleaning is the only way to achieve comfort. I accepted all the things that the student accommodation provided, even though I cannot have an LCD but it is fine.” Filardhi In contrast with the others, a comfortable feeling for Aiwen is when she does not have to take care of the room (physical related) and has some privacy for her spiritual activity and thinking (psychology related).

I consider it as a way to acknowledge comfort. Nonetheless, she also mentioned bed regarding physical comfort.

“For me, comfort equals convenience, comfort for me is to have sufficient elements for my basic requirements. I do not need anything luxury or advanced. I need just a comfortable bed and this bed is very comfortable.” Aekkalak

“I throw things around. Even though it is annoying but somehow it is comfortable.

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have to take care of them, and they do not get into the area that I am using… My bed [is my favourite spot] because everything happens here, it is the most comfortable spot in this room.” Aiwen

habitual activities, or maintaining the presence of familiar and meaningful objects) and support important sentiments. Some for example expressed the piece of their meaningful personal objects:

The following of this thesis discusses personal objects carried from home.

Apart from the comfort provided by the room itself, such objects hold a significant role in constructing comfort. I identified those objects as “comforting objects”. A set of questions was asked about the meaning of objects, both personal and new objects, to find out what the comforting objects are for my interviewees.

Most new objects that students brought in after they moved in are looked upon as ways to support physical comfort.

The personal, meaningful objects they carried from home, in contrast, are related to psychological comfort (can be attained by re-establishing experiences that are related to gratifying memories, such as engaging in

“The painting from my ex-boyfriend is the most meaningful object. Because he is one of the most important persons in my life and now I am here and cannot see him.

I brought it for this reason. And if someone took this painting, it is worse than someone took my wallet… I place it at the bottom right corner of the window. It is the most visible spot in this room, I do not look at it everyday but I know that it is there.” Liesbet In the context of temporary student housing, the compensation for psychological comfort can be constructed by personal objects. The relationship between one and one’s own object helps one to avoid a feeling of alienation towards the room. Most of the voluntary students could adapt them346

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selves to the room quite quickly, in approximately one to two weeks. It is because they knew that they would live with it and 6 months was bearable for them.

Everyone has a complex identity and background that defines him or her. It would not be reasonable to conclude their similarities and differences in this study.

However, it can be concluded that in the real home furniture provides the owner with both physical and psychological comfort and helps formulate one’s identity. In a temporary situation, furniture gives physical comfort without being a point of distinction from any other. This may also change during the stay, students could familiarise themselves with the furniture and it is the moment that ordinary furniture in the student housing has a role in constructing psychological comfort.

After students render their temporary rooms more personal by rearranging furniture and fill the space with their own things, their lives in the rooms begin. It is the initial moment of finding one’s own comfort.

This chapter captures how students inhabit their rooms by using drawings and diagrams, which are translated from my observations and documentations of their rooms to represent patterns of time and activities and spatial divisions inside the room. Drawings and diagrams together with the interviews provide an insight to this subject matter. Differences and similarities in occupying spaces by four students show that there are several ways to construct comfort in the space.

The room where most activities take place in one single space is a smallscale habitation. However, the way in which inhabitants experienced the size of their spaces differs. The existing situation drawings 348

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show that some students used the space in an efficient way while others did not. They employed different strategies of arranging the furniture and organising their spaces.

The latter turn ordinary student rooms into something totally different. I propose that it also affects how inhabitants experience the rooms as being bigger or smaller. This also depends on the amount of objects that they have and how they manage the positions of objects.

What did the inhabitants do in their rooms to construct comfort? The time that they spend on certain pieces of furniture and areas inside the room says a lot about comfort. In answer of my question during the interviews “Where do you relax in this room?”

I heard:

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happens here on my bed… I just need a bed, a computer and Internet access.” Aiwen “I relax on my bed. I read a book, listen to music, surf the Internet, and watch television. I like to be on my own.” Liesbet

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The responses of Aiwen and Liesbet related back to the discussion about comfortable feeling created by comforting objects.

The bed, again, reaffirms itself as a special object inside the temporary room. It will be further explained in this chapter the way bed is related to the construction of comfort.

Based on my observations, documentations and interviews, I translated the information into diagrams related to the four key activities that occur inside the room: dining, working, relaxing, and sleeping.

The information diagram (Pattern of time and activities diagram) presents patterns of time in relation to those key activities in an average calculation (the most regular situation of each inhabitant). The diagram illustrates how those activities occur for each student in an overlapping or separating sequence. For instance, Aiwen who does not have a clear definition of relaxing, the diagram shows that almost all activities overlap. For others there is a clearer distinction.

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This information could be read together with the spatial division diagrams to obtain a better impression of how the actual spaces were utilised by students. For example, Aekkalak who has the clearest distinction between activities (1) also has the clearest spatial division (3). The spatial division of his room is organised in a manner of standard home with not so many activities overlap in the same space. From the diagram, one could read that his comfort can be achieved by efficient spatial organisation, while others may not.

I also found the height in relation to the multi-functionality of furniture an interesting issue. Most of the time, furniture is designed to fit with human dimension, ergonomics, and comfort. Is it always true?

According to Baudrillard:

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are the result of an involuntary adaptation to a shortage of space. (Baudrillard, 2005, p. 15) Baudrillard’s observations raise questions related to the usage of furniture: do students use furniture as it is supposed to be used? Is an easy chair always for relaxing? Is a bed always for sleeping?

Baudrillard also comments on the multi-functionality of modern furniture. “All such objects, with their ‘pure’ outlines, no longer resemble even what they are.” (Baudrillard, 2005, p. 16) This quotation is also relevant for the usage of furniture inside student rooms. The way we label furniture is by its shape, form, and functionality, but the way students use it has transformed its original implication.

The spatial divisions diagram (1-4) provides an answer to the questions posed earlier. It shows the distribution of activities in relation to furniture and its functionality.

The colour coding only appears on the surface of active furniture in the room, and the

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proportion of colour refers to the importance of four key activities and time spent on each object.

The diagram shows that one single object can be utilised for several functions – one surface with more than one colour coding. The multi-purpose table has its named role as it serves the user with several functions, even as a storage.

The bed alone could unexpectedly alter itself into a multi-functional object in this temporary situation. For everyone but Aekkalak, beds were used to serve other activities apart from sleeping. In this case, undeniably, bed is the object that centres the physical comfort of the room and has a possibility of becoming a meaningful object that also provides psychological comfort. The frequency and time that student spends on the bed has developed the meaning of it. After student get used to its function(s), the bed not only provides the comfort but warmth and familiarity.

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Chairs are no longer used only for sitting while working, eating, or relaxing.

Some students use the chair as a storage where to put their bags and clothes on, and some chairs do not even have a function.

There are some interesting remarks from the respondents: “There are too many chairs for this tiny space, I put two of them [there are three chairs in the room] on the balcony and rarely sit on them. They just stayed there for 5 months.” Liesbet “I like soft surfaces more than hard surfaces, soft is comfortable and hard is not comfortable. I like to read and study on my bed because it is soft. I do not like the working chair because it is hard, so I use the easy chair instead. I just use hard objects to put my things on.” Filardhi The absence of a private dining area in the student housing affects the 356

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habits of students considerably. Students tend to close themselves off into their rooms for creating their own privacy and comfort.

The provided communal kitchen and dining area is not regularly occupied. The students only cook in the communal kitchen, some not even that, and prefer to take meals to their rooms and dine with computers and televisions by their side.

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“I dine in the communal kitchen for socialising. If there is no one in the kitchen, I will dine here watching television while I am dining. I like to sit on a couch while I am dining but here I do not have a couch, so I sit on my bed and use the working chair to place my feet on.” Liesbet “I cook in the kitchen and bring it here. I usually dine on the working table while I use my computer, but sometimes I dine on my bed if I want to watch television while I am dining.” Filardhi

“I dine on my bed, the whole body on the bed. I do not spend much time on eating, about 1 hour for 3 meals. I usually have quick food and I eat quite fast. After I finish my meal I put the plate on side table next to my bed… Most of the time, I cook in this room, so I do not have to go to the communal kitchen” Aiwen

Computers and televisions unconsciously become part of the dining ritual for the respondents. Their attention is thus no longer on the food and socialisation but on the electronic devices. The connection through the virtual world gains more attention. It provides the virtual doors that lead them back to the society; it is the substitution of the actual doors that cut them off from the actual socialising activities.

“I always place the rice pot and side dishes on the small table, then bring the eating plate to the working table and place it next to my computer… I spend just 5 minutes per meal” Aekkalak 358

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the proximate positions to make all of them visible. Their connections are based on the activities colour coded. All white objects are hardly involved with the person when the person inhabits the space.

The horizontal gridlines of the sectional diagram refer to 5 layers of specific vertical positions: 400, 650, 1000, 1650, and 2500 mm. The vertical gridlines refer to the invisible spatial division of the room. Looking from the left hand side towards the right hand side means reading the space from door to window. The sectional diagram is intended to represent what is going on in the room; which objects are related to key activities and realisation of the proximity of the inhabitant; at what height that student is most engaged; and how all these influence the construction of comfort.

The way the students occupy and mutate the space and objects somehow goes beyond description. The tendency of mixing and overlapping several activities are quite obvious. The surfaces of furniture with

There is not only the height of the furniture as mentioned that influences the shifting of functionality of furniture but also the interior monologue (the meaning was stated in the prologue) that students have in those rooms – the lives without negotiation.

Students utilised furniture follow their own aspirations and satisfactions not its function. From the spatial division diagrams one can read that bed becomes one of the most multi-functional and central pieces of furniture.

Chair becomes a storage. Refrigerator becomes a television stand and a cooking surface. It is not only the differences of functionalities given to the pieces of furniture but also the differences of overall organisation of the spaces.

Another set of sectional diagrams elaborates on the relationship between height of furniture and the distribution of objects. The diagram illustrates the abstract section of the room. The objects looking from plan view are laid on sectional view in 360

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more than three colour coded are always the furniture and the area that students spend most of their time when they are inside the room with. I believe that all those things they habitually do contribute to the construction of comfort because the instantaneous habits are most of the time straightforward in the situation of interior monologue.

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The System of Comfort Four final diagrams of each student were created to represent the construction of comfort. A comfort diagram is a simplified pictorial representation of interconnections between factors (objects) and consequences (personal comfort inside the room) showing the components inside the room together with a symbolic line notation. It provides us information about the relative position, arrangement and usage of objects in relation to activities, to help us understand the construction of comfort.

The way I present is separated the comfort diagram into two parts: 1) relationship lines and 2) objects, for the reason that one could easily distinguish the invisible layer of connections (that I had made visible) and the arrayal of tangible objects. The combination of the two parts became the system of comfort. It emphasises the daily routine that shapes the construction of physical comfort. It includes personal objects that influence the construction of psychological

comfort. The lines represent several direct relationships between two or more objects.

The system of comfort for each student is diverse. The four comfort diagrams represent the uniqueness of invisible patterns established by four students who inhabited four ordinary rooms.

For example, the following diagrams of Aiwen’s comfort diagram the relationship lines are evidently direct towards the area of bed and refrigerators, which are her favourite spots in the room.

How to read the diagram: (See color version on p 228-235) Green line - linked objects related to dining activity Yellow line - linked objects related to relaxing activity Red line - linked objects related to working activity Blue line - linked objects related to sleeping activity Two colours line - linked objects related to two activities Black line - linked objects related to non-four key activities Line thickness - thinner line = weak connection and thicker line = strong connection Large gap dotted line - linked objects that place underneath another objects Small gap dotted line - linked objects that supposed to be together White dot - linked more than two objects that have relation together

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AIWEN

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AEKKALAK

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FILARDHI

(See color version on p 228-235)

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Epilogue This is my bed, that is my wardrobe This is my lamp, that is my table This is my chair, that is my chair Is this my home? Yes, this is my home...

make them visible and understandable to everyone, not just through staying on the level of spatial research but making a visual representation of the students’ usage of space and construction of comfort.

According to the architect Bernard Tschumi, space per se doesn’t exist (Tschumi, 2006, p. 34.) Space cannot be comprised by itself; the formation of space needs an inhabitant, for the reason that the inhabitant is the one who recognised one’s own space and differentiated it from others, individually or collectively. The interior monologue is when a person recognised his or her space individually. The familiar moments inside the room transform anonymity to possession, from detachment to attachment. Every action in the living situation always happens on surfaces inside the space and all those surfaces contribute to one’s construction of comfort.

What is the interior architect’s role in relation to creating comfort then? The consideration of chosen furniture in the temporary habitation shouldbe taken into

After I investigated the rooms and interviewed four students who live under the same living conditions in a temporary student housing. I found that different individuals have considerably different ways of constructing comfort. They arrange the furniture in different manners, based on their own habits. They occupy the space in different ways, based on their own character. Their personal objects carried from home are somewhat similar, apart from the comforting objects.

This thesis contextualised comfort in the setting of ordinary objects of ordinary people. Students inhabit their rooms in their own specific ways. Comfort was present in their rooms, even though those rooms offered less freedom to create a home.

My aim was to present those differences and 372

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account. We should rethink about the role and function of the furniture inside the space. This may affect the size and shape of the room. This may influence the list of inventory to which some will be more dominant in the space, e.g. bed, multi-purpose table and some may disappear from the space, e.g. table chair, easy chair. This patterns could be altered if there is no condition of the interior monologue.

This research bringing together visual depictions of comfort and explanations of students could thus be perceived as a guideline of how we as interior architects could observe and make understand of the complexity of domestic architecture. The research could be comprised in a more sophisticated way in the context of home with more than one inhabitant. Although comfort is not easy to measure, I believe that this research could raise and trigger the awareness on how we, interior architects, address the way of living and designing spaces.

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The Healing Environment Reconsidered

Master Thesis

Naomi Cheung San

The Healing Environment reconsidered

The Healing Environment Reconsidered

Introduction

Naomi Cheung San

The term Healing Environment originated in the United States at the intersection of architecture and environmental psychology in the nineteen nineties. This idea, based on the simple conception that an environment can have a healing effect on a person, was not entirely new. The impact of the environment on people’s health was already recognized in the eighteenth century when statistics proved that life expectancy in the city was significantly lower than at the country side. Moreover, a significant part of nineteenth century urban policies was already characterized by improvements intending to make the city a healthier place to live. Near the end of the nineteenth century the political focus shifted from sanitary improvements like the instalment of a sewage system and clean water supply, to regulation of public housing in ways that pursued stable constructions, appropriate heating and enough green in the nearby living area. Additionally, the layout and design of the housing required 376

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Introduction

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The Healing Environment Reconsidered

1.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publisher, 2010.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009.

that it provided enough light, air and sun.

The abolition of psychological causes of disease now came down to offering a more ‘natural’ living environment, with the manipulation of the living environment used as the most effective way to improve health in the city.

In the beginning of the twentieth century the emergence of pathology, anatomy and bacteriology introduced a shift regarding health policy. Disease could now be directly contested within the individual patient. The rise of medical science with all its technological and diagnostic improvements suppressed the awareness that environmental aspects were structurally important for our health perception. Only in the sixties when the flipside of technological and industrial progress became visible, the importance of environmental aspects was rediscovered. For the first time, research from the psychological field pointed at the impact of ‘modern living’ in terms of stress, loneliness and boredom. In reaction to these 378

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new insights, environmental psychologists, architects and urban planners took it upon themselves to turn the tide and bring back ‘human scale’ in our daily surroundings.

Unfortunately, due to the introduction of the social security system after the Second World War and rapid improvements in medical technology together with the rise of new specialisms, the problem of scale enlargement became the ruling issue in healthcare architecture, pushing the philantrophic objectives aside. Only in the nineties when marketing strategies found its way in the healthcare system and technological developments started to offer more flexible possibilities, architects could finally elicit some radical changes regarding patient oriented healthcare architecture. 1 The concept of the Healing Environment particularly focuses on the reduction of stress within the designed environment. Apart from healthcare architecture it is also applicable to offices, factories, and all other types of environments. In particular,

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Introduction

the scientific basis underlying the proposed design approaches was a new phenomenon which gave architects the tools for justifying their design decisions. These environmental guidelines exist under the name of Evidence Based Design. Professor of Architecture Roger S. Ulrich is seen as the founding father of this field since he was the first to research the effect of a certain view from a window hospital on a patient‘s healing process. The results of this research were published in an article in the journal Science in 1984 under the title: ´View through a Window May Influence Recovery from Surgery.´ This research is still regarded as ground breaking since it validated the possibility of measuring the effects of the environment on human wellbeing.2 The concept of the Healing Environment pursues the design of healthcare institutes with specific attention to nature, view, sound reduction, daylight, use of materials, colour and everything else the patient needs for optimal healing. While

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2.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 327. (research results by Roger Ulrich are published on www. healthdesign. org)

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these environmental aspects seem to be logical considerations for architects, a lot of Dutch healthcare institutes seem to lack these basic requirements. Therefore the Healing Environment in the Netherlands is still mostly a reaction to the clinical and impersonal atmosphere in hospitals while the concept in the United States can be seen as a way to strengthen the competitive position of a hospital to attract more patients. But, in both strategies the objective is to implement a more patient-focused approach.

When implementing the concept of the Healing Environment on a larger scale, I believe the notion can exceed simplistic assumptions of ‘just adding some windows and plants to the hospital,’ and challenges us to question our perception of healthcare on a sociological base. By using the concept of the Healing Environment as a fixed notion within current thinking about healthcare, I want to come to a better understanding of the connections and implications that lie between the perception of health, 381

The Healing Environment Reconsidered

Introduction

Naomi Cheung San

The Healing Environment Reconsidered

Introduction

Naomi Cheung San

The first two chapters are deliberately divided in two sections of which the first sections focus on perspectives from fields outside architecture. Subsequently, the second parts of the chapters elaborate on the architectural point of view towards the subject. However, although the first chapter has a pretty strict division between architectural and non-architectural perspectives, the second chapter already introduces or rather suggests, the fusion of the different fields of medical science, architecture and environmental psychology. Successively, the last chapter discusses architectural projects in which the combined conceptions from all the discussed fields come together.

The first chapter of this thesis will discuss the perception of health from a sociological point of view. Mostly drawing from medical sociologist Michael Bury’s ‘Health and Illness’ (2005), I will give a general idea of the implications of health perception. I will elaborate on the terms ‘attributional’ and ‘relational,’ which Bury

the practice of healthcare, and healthcare architecture. This research pursues to find out how the concept of the Healing Environment reflects social and cultural conceptions about healthcare and what changes the practical use of the concept currently elicits in Dutch healthcare architecture. What is generally understood by the notion of the Healing Environment and how does it relate to the existing healthcare institute?, How does the Healing Environment reflect on social and cultural conceptions about healthcare in the past?, How does the Healing Environment connect to current philanthropic approaches within Dutch healthcare?, How is the concept of the Healing Environment currently being practiced?, and What possibilities does this enable for the near future of healthcare architecture?

This research will help me to find the space where current healthcare and healthcare architecture meet, in order for me to position myself as an interior architect within the field of healthcare architecture for the near future.

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uses to stress the blurring boundaries between the individual and the social, the patient and the medical professional, and the body and the mind, regarding health perception. 3 By focusing on developments within healthcare architecture, the second part of the first chapter will give a brief historical analysis of the institutionalization and socialization of healthcare in the Netherlands from the eighteenth century up till now. The chapter will point out that the rise of the healthcare institute runs parallel to the rise of the medical profession. The growth of population, the aging of society, budget cuts and technological improvements all influenced the way the healthcare institutes were designed, and affected the size, functions, organization, styling and location of the healthcare institutes.

The second chapter discusses current counter reactions to the overly regulated and systemized medical field within the Dutch healthcare institutes. It stresses a

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3.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005.

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new, more holistic view towards patients and proposes patient focused healthcare. The chapter takes the campaign Lief Ziekenhuis which is a five year long research and transition project currently running in the Elisabeth Ziekenhuis in Tilburg as an example. With the goal to become ‘the sweetest hospital in the Netherlands’ the campaign touches on many executive layers within the hospital.4 I will point out implications of semi-scientific research that focuses on making healthcare more philanthropic by digging deeper into the concrete, practical approaches, but also into ethical aspects of the campaign. By referring to Margo Trappenburg’s ‘Genoeg is Genoeg’ (2008), I will question the effectiveness of philanthropic approaches. I will zoom in on the patient and elaborate on how his position in society and in the healthcare system has changed due to the rise of increasing consumer-driven approaches within the medical field, the rise of patient interest groups and the increasing assertiveness of the patient. 5

4.

Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012.

5.

Margo Trappenburg, Genoeg is Genoeg. Over Gezondheidszorg en Politiek, Amsterdam: University Press, 2008.

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Introduction

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The Healing Environment Reconsidered

Introduction

Naomi Cheung San

care. The chapter gives some short examples of renovation projects that made use of the concept, which are mostly executed on the level of styling or interior architecture.

Next, I will discuss the design of the newly built ‘Maasland hospital’ by Bonnema Architecten and how it (possibly indirectly) relates to the Healing Environment.

In conclusion I will elaborate on the prize winning concept of the ‘Core Hospital’

by VenhoevenCS (2004) which focuses on decentralization of care. Next to general conceptions of the Healing Environment the project provides a new way of looking towards the Healing Environment on a broader sociological and cultural level.

From the discussion of the philanthropic approach of the Elisabeth Hospital I will jump to the environmental consequence of the new patient oriented approaches which is the Healing Environment. By digging deeper into the background and expectations connected to the notion I aim not only to gain better insight into its concrete effects on the patient’s healing process, but also into its impact on staff and organization of the hospital. The chapter will point out the different sociologic and architectural layers of the notion by elaborating on its origins but also on what is generally understood about the Healing Environment and Evidence based Design in the Netherlands.

In the last chapter I will point out what changes the Healing Environment currently elicits in Dutch healthcare by discussing architectural projects that make use of the concept. I aim to give a clear view of architectural interpretations of philanthropic healthcare approaches and will elaborate on what it could mean for the future of health386

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The Framing of Health Over Time

Naomi Cheung San

1. The framing of health over time 1.1. The perception of health

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1.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.3.

2.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p. 4.

1.1.1. Health perception, identity and the rise of the medical field Referring to medical sociologist Michael Bury, ‘the medical model of health, as we know it now, took on its main characteristics in the eighteenth and nineteenth centuries.’ During the nineteenth century, pathology and bacteriology uncovered underlying pathological processes and their particular effects. This brought a welcome break from the endless classification of symptoms which had been the main activity of medical practitioners up till then.1 The belief that specific symptoms gave rise to specific diseases was no longer valid, and symptomatic approaches were pushed to the margins of medicine as forms of ‘complementary medicine’ such as herbalism and

3.

Michel Foucault, The Birth of the Clinic: An Archeology of Medical Perception.

New York: Vintage, 1973, p.196.

4.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.4.

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homeopathy which treat symptoms ‘holistically.’ As a result of the newly gained knowledge, the medical profession gained power as ‘modern citizens were increasingly encouraged to see their health as an individual matter, and their health problem as in need of the attention of a doctor.’ 2 In ‘The Birth of the Clinic’ (1973) Foucault introduces the term ‘medical gaze’ to refer to the anatomical experiments that eventually led to the birth of modern medicine. He describes the break as the ‘medical gaze’ shedding light on death which resulted in ‘disease breaking away from ‘metaphysical evil.’’ 3 The new developments caused the medical model to become more ‘individualistic in its approach and to pay less attention to patients’ social situation or the wider environment.’ 4 In the middle of the nineteenth century the question rose whether political decisions concerning healthcare should be based upon the belief that disease is caused by either biological characteristics or by the impact of the social environment.5 When the

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field of psychology expanded its reach to the field of healthcare, ‘health development and social development became inevitably interconnected’ and, according to Bury, the sociology of health became recognized as its own field, leading eventually to the current ‘multi-factorial model of illness wherein both physical, psychological and social processes are recognized as playing an important part.’ 6 According to Bury our health perception is determined by ‘a state of complete physical, mental and social wellbeing’ rather than the absence or presence of disease.7 In that respect stress, fatigue and nervous tension connected to a certain lifestyle play a bigger role than physical illnesses.

To illustrate this, Bury emphasises that nowadays we often take meanings concerning our health for granted. According to him health, as a feature of our daily life, has been marginalized into a part of ‘the natural attitude to life’ and the ability to cope with everyday activities.8

Naomi Cheung San

5.

This contemplation refers to the ‘nature versus nurture debate’ which concerns the relative importance of an individual’s innate qualities versus personal experiences in determining or causing individual differences in physical and behavioral traits.

Political approaches based on ‘nurture’believes would focus on the change of lifestyles rather than invest money in healthcare institutes.

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6.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.13.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.33, 232.

7.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.8.

8.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.7.

9.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.9.

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It is recognized within the medical field but also by healthcare architects as we will see later on, that a patient’s identity plays a big role for his own health perception and healing process. According to Bury ‘illness runs the risk of devaluing a person’s identity, either because its causation or because of inappropriate behaviour in the face of symptoms’ which can be explained as a departure of social norms.9 When an individual feels that he is losing grip and control over his body, his mental wellbeing can in turn be affected, but the perception of our own health is not necessarily a combination of physical and mental health. This is especially true for individuals suffering from a chronic illness such as diabetes, as they may still define themselves as healthy despite their disease. It seems that health perception is not only influenced from the outside; ‘the nature of the stability of the disease is of importance for the adaption of the individual to its physical state.’ ‘Adaption to illness or disability alters the baseline from

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which the individual judges the nature of health and its implications.’ 10 Thus, feeling healthy has to do with a degree of control, the use and the presentation of our bodies which in turn strengthens our sense of identity. ‘The presence or onset of chronic illness or disability threatens to compromise this social ‘performance’ –located within a set of social and cultural expectations and demands- and leads to a series of implications for ‘self management.’’ 11 1.1.2. Considering health in terms of ‘attribute’ and ‘relation’ Bury approaches tensions between the medical perception and the social perception of health by considering health in terms of ‘attribute’ and ‘relation’. The tension between these different approaches lies parallel to implications of the Healing Environment and the Evidence Based Design concept which will be discussed in the next chapters. I will first elaborate on the different approaches and give some concrete exam-

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10.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.9.

Naomi Cheung San

ples of the presumed tension between them.

Seeing health as ‘attributive’ is connected to health perception as it existed in the early nineteenth century when ‘pathological anatomy’ gave birth. It presupposes that disease is an entity seen separate from the body and therefore separate from the person as an individual. The disease then becomes a ‘property or attribute of the individual.’ 12 In contrast, Bury describes a relational view of health which can be described as ‘social or psycho-social forces that influence the pattern and expression of illness.’ ‘This can be conceptualized in two ways: either in terms of the ‘social creation’ of illness patterns through inequalities or environmental factors, or in terms of ‘social production’ of illness in individuals through the contingencies and negotiations that surround its identification, naming and treatment.’ Within a relational perspective ‘the process of recognizing or naming a disease, by medical staff or patients, involves a range of factors, including the severity of symptoms, the age

11.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.75,76.

12.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.12.

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393

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and tolerance level of the sufferer, the social circumstances of the individual, and the interactions between the person and the healthcare system.’ 13 Considering health in terms of attribution and relation indicates a division between the body and soul. Understanding the body is central to the understanding of the individual experience of illness and health since we, often unconsciously, base the perception of our own wellbeing on signs our bodies give us.14 In the seventeenth and eighteenth century, the body was seen as a system of mechanics and hydraulics. Referring to Descartes, the mind was seen as an entity separate from the body and unlike the body, did not have to obey natural laws.

This distinction which is essentially about the contrast between nature and nurture or body and society, was food for much contemporary and radical thought. Treating the body as a machine was a powerful resource for improving knowledge about the body, and was a means of significantly increasing the

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13.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.12.

14.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.7961.

15.

Michel Foucault, The Birth of the Clinic: An Archeology of Medical Perception. New York: Vintage, 1973.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.63.

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17.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.67.

An example of a social intervention is the normalization of obesity by commercial organizations through media and by opening XXXL department stores. Additionally, the rise of plastic surgery interventions also indicates a normalization of the procedure.

16.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.64.

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health of the public instead of the individual, but also ‘invalidates important aspects of experience, and could be used by healthcare practitioners as an excuse not to recognize the subjective nature of illness.’ 15 Currently, knowledge about experience and the impact from outside on our bodies has made the approach of the body as machine outdated. Bury stresses that when discussing ‘health,’ it is better to refer to the body and the social environment as ‘interactive.’ ‘When viewed as a process unfolding over time, the body itself is shaped and altered by social processes and in turn interacts with the environment to produce particular effects.’ 16 ‘The body has taken on particular salience in a culture dominated by greater individualism and self-awareness, and in an economy which emphasizes consumerism and body maintenance.’ ‘In such circumstances the line between the natural and the social becomes blurred, as the body is manipulated and altered by technical and social interventions.’ 17

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The Framing of Health Over Time

Naomi Cheung San

A relational view of health draws for a considerable part on the ‘patient experience.’ It is the particularities of experience that give meaning to illness for the individual. Currently, better treatment and diagnostic techniques causes relatively more people to live with an illness. As a result, illness experience becomes increasingly important in healthcare today, as illness is increasingly experienced as a part of life. One could state that ‘patients are reclaiming their bodies and their illness from modern medicine.’ 18 Chapter 2.1. will elaborate more on the implementation of ‘patient experience’ in current healthcare approaches.

One of the examples of a disease or illness that is referred to as a relational and social phenomenon rather than an attribute of the individual is obesity. Over time, a significant change can be noticed in medical textbooks in the presentation of obesity, in which the emphasis shifted from the excess of calorie intake to the body, as a sign of over indulgence, to an emphasis on the

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18.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.70.

Naomi Cheung San

patient experience, as a sign of social deprivation, a shift which especially occurred in the twenty-first century when authorities started treating obesity as one of the most serious public health problems. According to Bury ‘medicalizing a problem such as obesity by defining it as a disease, can lead to its transformation from a moral or social issue’, which can be explained as a ‘social creation’, ‘ into a medical or technical one’, which can be explained as ‘social production’. This sets up an important tension: On the one hand there is a reduction of stigma and moral opprobrium attached, but on the other hand it is disguising or avoiding the moral or political issues that underpin the problem.’ 19 An example of the tension between the relational and the attributive approach is the debate regarding the terminology of ‘disabled people.’ Patient interest organisations suggest approaching them as ‘people with disabilities’ rather than ‘disabled people’ because it presupposes a more

19.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.111.

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social approach that takes distance from the physical attribute of individuals. But, according to Oliver (1990) cited by Bury, the former term insists that ‘disablement has nothing to do with the individual’ and therefore the experience of the disabled person, which can be highly important for the perception of his situation, is completely disregarded.20 As a solution Barnes and Mercer (2003) plea for a more eclectic and nuanced approach which also recognizes the pain and loss of people living with disabilities. They suggest an approach towards disability based on a ‘sociology of embodiment’ which brings together the subjective experiences of individuals and the broader contexts in which they occur.’ 21 There seems to be a distinct difference between the ‘consequences’ of illness and its ‘significance,’ which can be especially striking for chronically ill patients. The significance of the illness is often socially embedded while the consequences of the illness can disrupt the individual’s physical wellbeing and his or her relationships with

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20.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.73.

Naomi Cheung San

others simultaneously. Furthermore, certain disseminated healthcare perceptions often linked to serious physical illnesses are presumed to be caused by bad lifestyle choices while other ‘mental’ illnesses can be particularly linked to the person’s self or behaviour. 22 The influence of social acceptance and assumptions on an individual’s health is complex, especially when certain ‘mental’ illnesses can be produced by social contingencies. What is considered a disorder differs per culture, or rather, per context, but ‘once labelled, the individual is likely to take on characteristics of the label.’ 23

21.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.75.

22.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.16.

23.

For example: certain religious communities still consider homosexuality to be a disease.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.19

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1.1.3. The relation between health perception and medical science The general perception of health is very accurately derivable from the way a country or region organizes its healthcare.

In Western society, healthcare is highly valued and forms a priority for most governments. This most probably has to do with more individual and moral considerations in 399

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which healthcare ‘stands between the individual and some of the most serious personal experiences that can occur across the life course, whether they relate to birth, ill health or death.’ 24 Over the last decades, modern healthcare systems have expanded considerably, and the types of treatment of various illnesses have grown exponentially and diversely. Judging from statistics like ’mortality rate’ and ‘life expectancy,’ health has improved immensely but it is not at all clear that health improvement is caused by the growth of healthcare systems. It can be argued that measurements taken by the government to improve living standards could be a result of either social or economic improvement, or simply a healthcare measure.

Another reason for the unstable position of healthcare when evaluating health lies in the healthcare system itself. The evaluation of healthcare outcomes after or in-between clinical treatments for individuals has become an important matter for the whole

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24.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.81.

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of society, since many of the thousand treatments prescribed by doctors in early modern medicine up to 1930 were proven to be ineffective. 25 The need for scientifically based proof on the effectiveness of treatments from healthcare services was answered by the implementation of Randomized Controlled Trials in the seventies, which consisted of using placebos for certain routine treatments. By leaving the general healthcare practitioner out of the trial, healthcare for the first time in history could claim objective checks on the effectiveness of treatments, thus finally confirming an ‘evidence based healthcare.’ 26 This newly found optimism in the medical field was tempered by concerns coming from the field of practice. The first concern was the tension in the relationship between clinical practice and scientific evidence. For general practitioners the RCT’s seemed to be a form of surveillance. It soon became clear that evidence-based practice and a patient orientated approach did not go

25.

Michel Foucault, The Birth of the Clinic: An Archeology of Medical Perception.

New York: Vintage, 1973.

Foucault elaborates on the protection of the medical field against charlatans.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.86.

26 Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.87.

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together very easily. The second concern regarded the patients. The view of the patient became more important when consent was required for patients to engage in the RCT’s.

Patients were not always happy to function as an experimental object and frequently based their opinions on their own healthcare experiences, despite the evidence-based medicine outcomes. Still, evidence-based medicine instigated a series of changes in the process of care under which a hierarchical shift would occur within the patient-doctor relation. 27 The newly found role of the patient shed light on a different type of model regarding medical decision making. Instead of the doctor imposing his will and the patient being an obstruction to proper decision making, medical etiquette in clinic encounters involved the doctor diagnosing as well as listening, while also explaining things in a language that was understandable for the patient. Research by Charles (1999) cited by Bury, made a distinction between the ‘pater-

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27.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.89.

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nalistic model’ where doctors are trusted to make decisions in the patient’s best interest and therefore give the patient only little information, and the ‘informed model’ where the doctor assents that it is the patient who has to live with the consequences of the treatment so it should be the patient who makes the decision.

In between the ‘paternalistic’ model and the ‘informed patient’ model stands the ‘shared decision’ model that has become more popular in policy circles in recent years. In this model there is a two way process of information giving and receiving.

Given information should be relevant for decision making and the final decision is jointly made. The success of this model depends on a critical adaption onto different groups of patients and their support systems since it is recognized that some patients function and cope better with less information.28 In addition to the above considerations of changes in ideology and practice in the processes of healthcare, there were also 403

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major changes in the external environment in which healthcare systems operate. With the rise of the new media in the nineties, patients became more assertive and involved.

This eventually resulted in the foundation of patient interest groups and the implementation of internal complaint procedures for handling patient concerns within healthcare institutes.29 Accountability and transparency became keywords in healthcare policy and opinions on professional healthcare were no longer a privilege of the medical professional alone, which put even more pressure on the doctor-patient relationship. The changing nature of mass media coverage of health and healthcare created a dynamic of its own as healthcare processes, whether fictional or factual, became a regular topic of discussion on radio and television. 30 In contrast to times where medical information was kept from the media to avoid anxiety, current extensive media coverage of medical failures scaled down the autonomy of the medical professional even further. 31

Naomi Cheung San

27.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.90-93.

29.

Margo Trappenburg, Genoeg is Genoeg. Over Gezondheidszorg en Politiek, Amsterdam: University Press, 2008.

30.

Examples of medical television programs: Greys anatomy, ER, De co-assistant, Jonge dokters van het OLVG, etc.

31.

An subject of extensive media coverage of a medical failure was for example the outbreak of the klebsiella

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bacteria in the Maasstad hospital in 2010 which reached all the national newspapers.

32.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.96.

33.

Margo Trappenburg, Genoeg is Genoeg. Over Gezondheidszorg en Politiek, Amsterdam: University Press, 2008.

Karen Heijne, ‘Zorgboulevards. EGM Architecten’, Architectenweb Magazine, 45, 2011, p. 54-59.

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Changes like these ’in the context of healthcare revolve round alterations in expectation and structures.’ ‘A more informed patient oriented approach to healthcare consumption is coinciding with a more pluralistic form of healthcare provision.’ 32 All sorts of health services under which wellness centers and ‘care boulevards’ came into existence together with the rise of non clinical practitioners like acupuncturist and herbalists. It can be debated whether their definition of health coincides with that of the medical field. 33 Markets for health, both orthodox and complementary, seem to become ever larger by ’simultaneously meeting and exploiting expressed needs.’ Bury concludes that the more sensitive we become for the signals of our bodies, the more easily we assign these symptoms to a given ‘attribution.’ 34

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1.1.4. A dynamic approach towards health for more efficient healthcare Recent developments within healthcare have its effect on expectations of the provided healthcare. ‘The decline in the autonomy of medical practitioners’, and ‘pressure to develop a ‘partnership’ approach with patients is now finding a way into formal policy initiatives.’ 35 Improving quality, providing choice and setting certain standards (like the amount of waiting time before an operation), are only some examples of the extensive initiatives. Unfortunately cost effective healthcare practice and the pressure to evaluate treatment and promote evidence-based practice is often getting in the way of patient-oriented healthcare practice and causes tensions between management and practitioners.

No matter how much health has improved objectively (better environments, lower mortality, longer life expectancy), ‘reportings of health problems continue to grow, rather than diminish.’ ‘The social con-

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34.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.115.

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text of health and illness in contemporary societies, include the blurring of boundaries, the extension of medicalization and medical surveillance.’ 36 Furthermore, the perception of health is not single or unitary: it has a different meaning in different areas of life and concerns different lifestyles and/or cultures. 37 The blurring boundaries between medical, social, and psychological needs challenge both social and ethical thought.

Commercial interest in medical intervention forges ahead to an extension of medicalization within a society where everybody is potentially ill.

Conflicts between subjective experience, medical science, and authority became more prominent when the medical model changed from being exclusively based on a pathologic anatomical view to involving patient experience. When addressing preventive measures ranging from environmental changes to genetic treatment, it is hard to give a clear-cut definition of healthcare. Bury pleas for a dynamic

35.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.96.

36.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.102.

37.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.9.

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1.2. Healthcare institutions approach where the model of attribution which is closely linked to the medical model of health is dialectic with the relational, sociologic model in order to strengthen one another and to come to better understandings of health and healthcare. 38 Within healthcare, architecture takes a special place, for the design of the healthcare institute can be read as a history of sociologic and cultural conceptions about healthcare. ‘In no other building typology is the relation between location, organization, function and design so direct as in healthcare architecture, and nowhere else is the relation between buildings and the physical and mental wellbeing of the people whom it is designed for, so intense.’ 39

38.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.115.

39.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 7.

408

1.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 26.

2.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 26.

409

1.2.1. First examples of hospital architecture – healing rituals The historical revolution of hospital architecture cannot be described as a linear process. ’Long periods of slow transition alternate with sudden changes.’ 1 Buildings especially designed for healthcare can be traced back all the way to ancient Greece. Back then, the concept of healing was closely linked to religious rites and rituals causing the hospital to manifest itself as a classical temple. In that respect, the religious temples are comparable to the monastic hospitals of the Middle Ages, which resemble monasteries. 2 On the contrary, ‘the hospitals constructed by the bourgeoisie in Europe’s rapidly growing medieval cities stand apart from the religious institutions. They were civic buildings commissioned by the municipality and were usually constructed as

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spacious halls with high pitched roofs.

Though often run by religious orders, they are definitely civic, urban buildings, founded either by wealthy merchants or by city governments.’ 3 The Ospedale Maggiore, founded in Milan in 1456, and designed by Antonio Averulino, was the first hospital to be designed according to geometrical principles of the Renaissance. ‘It is a symmetrical composition with a large central courtyard; on both sides of it, the wings of the building delineate four smaller courtyards.’ 4 Breaking away from the many hospital buildings that were structured around courtyards, F. Beer designed the first ‘corridor hospital’ in Bern which was built between 1718 and 1724. Hospitals of these type looked like schools; they were integrated in the street facades and they were built according to a symmetric layout in which men and women were separated. 5 Even before the rise of the ‘corridor hospital’ the political-economical concept of mercantilism grew its roots in seventeenth

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3.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p.

26-28.

4.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 28.

5.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p.

28.

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6.

In France the centralized state took responsibility for the hospital. In Great Britain private citizens were responsible for the build of new hospitals.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 28.

7.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 28.

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century society. Mercantilism disseminated the idea that the economic success of a nation depended largely on the output of the labour force. The special measures that were deemed necessary to keep them fit, resulted in the increase of hospitals mainly in the eighteenth century. It differed from country to country whether the government or private citizens themselves took responsibility for the hospitals.6 ‘Until the beginning of the twentieth century, hospitals were often conceived as representational civic and, occasionally, military, buildings. By the middle of the nineteenth century however, these concepts were considered outdated; for the pavilion type with its small structures spread out on relatively spacious green plots, and its central axis separating the men from the women, had conquered the world. 7

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1.2.2. A breeze of fresh air - the pavilion type Although the medical sciences made steady process during the eighteenth and nineteenth century, they were not yet based in the hospital. A change was initiated when statistical research pointed out that ‘most contagious diseases started in the poor parts of the city, where hygienic conditions were the worst.’ Frome then on ‘clean air became one of the priorities in the campaigns to improve healthcare,’ which resulted in a critical analysis of existing hospital types such as the ‘corridor type’. 8 The first pavilion type hospital was built between 1839 and 1854 by the name of Hopital Lariboisiere designed by M.P. Gauthier. The tremendous success of the pavilion type hospital all over Europe was based on the revolutionary idea that under more by offering clean air, the hospital could ‘heal by architecture’. Especially in France ‘the medical doctors were deeply involved in revolutionizing the hospital. The reformers suggested that the healing qualities were

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8.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 28-29.

J. Geri, Allgemeines Krankenhaus, Vienna, 1783.

Example of a pavilion type hospital. source: http:// en.wikipedia. org/wiki/ File:AAKH1784.jpg (last entered: 01-07-2012)

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derived, not from medicine, but from a purified, natural environment that provided clean air.’ 9 Around 1900 the discovery of the bacteria introduced the rise of medical technologies. This development eventually caused the hospital to cast his function as a big air-freshening machine. The alleged beneficial effects of nature became only a secondary reason for the use of the pavilion type. Instead, ‘the pavilions reflected the growing specialization in the medical world, each harbouring its own discipline and operating as a small hospital in its own right, merely sharing collective facilities (the kitchen, for instance) with the other pavilions.’ 10 Breaking away from religion and superstition the hospital became ‘the first building typology in the history of architecture.’ ’ From then on the evolution of healthcare buildings was almost entirely determined by beliefs about its functioning. 11 Although the hospital indeed helped patients to overcome their illnesses, ‘the hospitals were primarily social

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9.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p.

28-29.

10.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 2931.

11.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010,

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p. 9.

In the Netherlands, architectural consequences of the Enlightenment only occurred from the middle of the nineteenth century. From then on Dutch healthcare architecture developed relatively fast.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 13.

rather than medical institutions. Wealthy patients avoided hospitals at all costs – they were almshouses for the poor.’ 12 Cor Wagenaar (2006) emphasises that the modern hospital of the late eighteenth century was ‘a symbol of revolutionary victory’ and that its ‘emphasis on the influence exerted by the environment on the healing process – indeed, to the neglect of most other factors – the modern hospital of the late eighteenth century can also be seen as a precursor of Evidence Based Design’ which will be addressed in the next chapters.13

12.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 31.

1.2.3. The influence of medical science and technology – block types With the introduction of technology, starting with the Röntgen machine, into the medical field near the end of the nineteenth century, the social function of the hospital was slowly overtaken by its medical-scientific function. ‘The hospital service became out of reach for the poorest classes and the

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transition from almshouses to top medical institutions was quite remarkable. Apart from their role as training institutes for doctors and nurses, hospitals had never before been in the vanguard of medical science and technology.’ 14 The technological machinery was too expensive to0 be owned by individual doctors and the hospital became the logical place to concentrate them. ‘Along with it came the medical specialists, and within a few decades the hospital developed from an almshouse into a temple of the medical world.’

‘Medical doctors, the machine, and the (urban) elite now dominated the hospital.’ 15 Both architects and medical staff were more than happy to abandon the pavilion type; the walking distances for the -2 staff were immense and for the architects the separated small buildings of the pavilion limited their creativity. The pavilion type was replaced by a more compact ‘block hospital’.

Unlike its predecessor, the compact charac-

Naomi Cheung San

13.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p.

31.

John Thompson and Grace Goldin, The Hospital: A Social and Architectural History, New Haven and London: Yale University Press, 1975, p. 3-14.

14.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 31.

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15.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 32.

16.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 32.

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ter of the block type lend itself perfectly well to being designed as a big representational building. But, even though great and monumental, the ideal of the essential architectural quality of creating a healing environment, as pursued in the pavilion type, was nowhere to be found in the new high rise buildings. ‘The natural environment ceased to be a factor in hospital design.’ ‘Everything in the huge and very urban buildings is subordinated to needs of science and technology.’ 16 The types were often named after the letters they resembled. An example of the T-type is the ‘Diaconessenhuis’ in Breda, built in 1960. The polyclinics are situated on the ground floor of the 4 floors high treatment-department. The bed ward which was also 4 storeys high, was placed perpendicular on the treatment department creating a T-shaped floor plan.

Within the H-type polyclinics and treatment departments are separated from the bed ward by a connecting part that houses functions which require a central location like

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M.F. Duintjer en D.J. Istha, Diaconessenhuis, Breda, 1960.

Example of T-type hospital.

Source: Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 122

17.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 109.

J.P. Kloos, hoofdopzet Diaconessenhuis, Groningen Example of a K-type hospital built in 1965.

Source: Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 122.

18.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 121-129.

W.F. Lugthart, Diaconessenhuis, Eindhoven, 1956-1966.

Example of ‘BreitfuB’ or ‘tower on podium type.’

Source: http://www.eindhoveninbeeld. nl/foto.php?foto=1511 (last entered 01-07-2012)

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the kitchen, management and operation department as in the ‘Rode Kruis Ziekenhuis’ (1950-1960) in The Hague. 17 The K-type was a variation on the H-type in which a curve was added to the bed ward. At the location of the curve or crack, a central function could be added like the chapel in the Diaconessenhuis (1963) in Leiden.

Another block type hospital came from America and was very popular during the sixties because of its flexibility in organisation. The ‘Breitfuss’ or ‘tower on podium’ – type houses the polyclinics in a widely arranged low rise building-volume which makes the introduction of new medical equipment relatively easy to realize. The high-rise bed ward-building is situated on top of the lower building taking in consideration that the bed ward was less subjective to technological changes.18

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1.2.4. Developments of Dutch healthcare architecture – post war healthcare architecture Through the centuries, Dutch healthcare architecture has not been very revolutionary. Dutch architects and builders mainly followed developments in the rest of Europe and the United States. Until the nineteen forties the Dutch hospital was still mostly a combination between the pavilion type and the corridor system, but the Second World War introduced a radical change in the thinking about healthcare. ‘Social segregation was seen as one of the causes of the war, and, generally, of people’s propensity for irrational behaviour towards each other.’ 19 ‘Since taken over by medical staff and by medical technology, hospitals had become symbols of this social segregation, accommodating only the wealthier strata of the population.’ 20 Like in other countries, the war had inspired the Dutch government to establish an extensive system of social security. From now on healthcare should be accessible to everyone and the architecture .

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19.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 35

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of the hospital should be a translation of that ideal. On top of that, the built of new hospitals was also seen as the alleged solution to the capacity problems in the Netherlands.

It seemed that the hospital was about to regain its role as social institution.

Resulting from the new social intensions, the architecture of the hospital was supposed to disseminate two messages at once: in the first place it should be a representative monument of the welfare state and in the second place it should be a functional building for the masses. Consequently this resulted in a strict division between bedwards, polyclinics and treatment departments, a layout which is still used as a base for current healthcare architecture.

The bed-ward was seen as the most important part of the hospital. One nursing unit would contain between 24 to 36 beds and was placed under the supervision of one head nurse. It was important that the bed-ward be organized in an efficient way that limited the walking distances for

20.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 35.

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the nurses. In principle the polyclinic was a place where ambulant patients could get medical attention, but soon its activities expanded to administrative and organisational functions. The treatment departments were seen as ‘healing machines’ with windowless operation rooms as the most important spaces. The treatment department was usually isolated from the other parts of the hospital. 21 The first twenty years after the war were characterized by industrialisation, fueling new economic and social relations which had its consequences for healthcare.

‘Between 1950 and 1960 the amount of beds in hospitals increased from 42.000 to 58.000 and the amount of medical operations doubled.’ In the second half of the sixties, five to six new hospitals were opened every year and there was an increasing amount of hospital merges. 22 Standardisation of construction elements and a fixed system of measures helped in handling the increased scale. 23

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21.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 81-89.

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Rapid medical technical improvements caused a spectacular growth of the polyclinics. Because the medical equipment soon grew old, the buildings were already outdated before the built was finished. In result hospitals were constantly rebuilding.

Increasing medical specialisation resulted in the demand for new spaces that could meet specific demands. The requested flexibility caused architects to experiment with the division in bed wards, polyclinics and treatment departments by organizing them in the discussed ‘block types’.

22.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 122.

23.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 155-157.

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1.2.5. Patient empowerment – the decline of the block types ‘Modern society, fully planned and controlled, appeared to limit people’s personal life by subordinating almost everything to bureaucratic institutions that were run either by the state or by big business, and that, in both cases, were oblivious to the personal concerns of the people they served.’

Cor Wagenaar (2006) emphasises that 423

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24.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p.

37.

25.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Uitgevers, 2010, p. 161-169.

Architektenburo Roelfs Nijst Lucas, Sint Elisabeth Ziekenhuis, Tilburg, 1973-1982.

Example of ‘kam-structure.’

The ‘kam-structure’ made it possible for the different departments to expand to the outside when necessary. The building is also an example of a hospital which is limited to its own plot. The relation with the surrounding city is pursued by the build of a ‘care-boulevard’ which you can see on the left side of the picture. The ‘care-boulevard’ of the Elisabeth Hospital was the first in the Netherlands build in 2001.

Source: http://www.ncct-nl.com/ ncct_home_NL.html (last entered: 01-07-2012)

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imperfections of modern society in turn reflected on hospital culture: ‘Patients were not treated as persons, but rather as a collection of possible diseases, all of which were the exclusive domain of medical specialists.’ 24 The beginning of the seventies announced a provisional end of economic growth. The social system had reached its limits: between 1953 and 1970 cost of healthcare increased almost tenfold, partly as a result of the increasing amount of general hospitals and beds. The Dutch government decided to regulate the built and locations of the hospitals along with the placing of expensive medical equipment.

Family doctors obtained the role of ‘gate keepers’ and guidelines were set to regulate the amount of beds and square meters per patient. ‘Restraint’ and ‘control’ became the new keywords in healthcare and for the first time the autonomy of the doctor was questioned. 25 The increasing critique on the massiveness and impersonal character of

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the hospital challenged architects to think in terms of small scales, security, and protection instead of organisation, technique, and logistics. ‘Instead of fragmenting the patient into diseases that correspond to the various medical specialities, the hospital organization should be built around the individual patient, respecting his or her personality.’ 26 The block type hospitals were now looked upon as monuments for the medical staff and the bureaucratic welfare state, and did not reconcile with ideals that recognized different ‘lifestyles’ and ‘self determination of the patient.’ 27 In addition, the integration of mechanical transportation devices made the ‘factory-like’ block-types with their short walking distances irrelevant. Low rise hospital buildings that almost felt like small villages of their own, made their first appearance.

‘Whereas the main functions of the hospital were clearly expressed in the T, H and K types of the 1950s and 1960s, hospitals now

Naomi Cheung San

26.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 38.

Annemarie Mol, The Body Multiple: Ontology in Medical Practice, Durham and London: Duke University Press, 2002.

27.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 23.

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28.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 38.

29.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p.

161-169.

Noor Mens and Annet Tijhuis, De Architectuur van het Ziekenhuis.

Transformaties in de naoorlogse ziekenhuisbouw in Nederland, Rotterdam: NAi Publishers, 1999, p. 157-173.

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became anonymous places in the larger grid.’ 28 Overall, there existed a preference for natural living circumstances over alienating environments while at the same time endorsing the positive effects of technical and economic progression. The hospital became interpreted as a big therapeutic society in which patients and staff were at the same level and care and cure were firmly intertwined. Unfortunately, holistic intentions did not yet really find their way into the healthcare architecture of the seventies. Despite good intentions the desire for flexibility overruled the philanthropic approaches, resulting the seventies and eighties to be characterized by hospitals built to expand. 29 1.2.6. From flexible structures towards management and marketing ‘The hospitals built in the eighties were structures based on internal traffic rather than buildings. Instead of architec-

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Kruisheer + Hallink architecten/adviseurs, ontwikkelingsplan Academisch Ziekenhuis Groningen, 1976.

Example of a hospital which is fully integrated in the urban tissue.

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30.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 198.

Source: Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 164.

Tuns + Horsting Architekten, Wilhelmina Ziekenhuis, 1990.

Example of crossstructure.

31.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 38.

Source: http://www. dr-yep.nl/ ziekenhuis/ wilhelminaziekenhuisassen/ (last entered: 01-07-2012)

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tural solutions they became attempts to restrain the inevitable process of adjustment and expansion.’ 30 ‘Some plans were made where the hospital is fully integrated into the urban tissue and no longer recognizable as an individual building’, while other hospital buildings were limited to their own plot and did not relate to the city at all. 31 The former was regarded as most ideal because in this way the hospital would belong to the patients instead of being a symbol for medical supremacy. The intention was to break down the walls between the hospital and society.

One of the first used structures in the Netherlands is the ‘kam-structure’ which forms the base of the Elisabeth hospital in Tilburg (1973-1982). Although it is a relatively big hospital, the organization within separated departments which are all attached to a central main traffic axis strengthens the feeling of being in a small scale hospital.

The different departments can be expanded at the outer ends.

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Other common structures are the linear structure, the cross structure and the carré structure. The linear structure is a variation on the ‘kam-structure’ which initially can be expanded on two sides. Within a ‘cross-structure’ the departments are turned and put perpendicular to the main axis which enables an atrium to be placed in the place where the different parts cross each other.

Lastly the ‘carré-structure’ is a combination of different kinds of ‘cross-structures.’ 32 The pursued flexibility of the hospital building demanded the hospital interior to be as neutral as possible. Only the design of the patios, courtyards and entrance halls gave architects relative creative freedom.

These alive and public spaces often formed a sharp contrast to the cold and sterile medical departments beyond the swinging doors. 33 Healthcare architecture of the later eighties and nineties represented a further evolution of the structural projects from the late 1970s and ‘manifested itself in huge halls, large passageways, covered streets

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32.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 227-231.

33.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 196-199.

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34.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 38.

35.

Cor Wagenaar, ‘Five Revolutions: a Short History of Hospital Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 41.

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and squares filled with shops boutiques and even restaurants.’ 34 On top of the intention to make flexible buildings and connect to the surrounding city, the nineteen nineties were characterized by a serious reconsideration of the welfare state which initiated the transition towards a more ‘management-dominated’ hospital. ‘Promising the empowerment of the patient, the market claims it can deliver what the counterculture of the 1960s – an ideologically inspired, collective movement for the liberation of the individual personality – could not.’ 35 Hospitals merged to stimulate effectiveness and the government tried to reduce the costs by regulating the offer and aimed to drastically bring down the amount of beds.

In 2001 the first ‘care boulevard’ of the Netherlands was opened in the Elisabeth hospital in Tilburg. By placing medical and commercial companies inside or near the hospital a ‘care boulevard’, which resembles a shopping mall, is created.

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36.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 280-282.

Karen Heijne, ‘Zorgboulevards. EGM Architecten’, Architectenweb Magazine, 45, 2011, p. 54-59.

Architektenburo Duintjer Ishta Kramer Van Willegen, Architecten- en Ingenieursbureau ir. D. van Mouril, Academisch Medisch Centrum (AMC), Amsterdam, 1981/1985.

Example of covered courtyard in the central hall of the medical centre.

Source: http://www.parool.nl/parool/nl/4/AMSTERDAM/article/ detail/3196760/2012/02/23/ Stadsgezichten-AcademischMedisch-Centrum.dhtml (last entered: 01-07-2012)

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In a way this commercial approach connects to the ideal of patient oriented care since it offers choice and empowerment to the patient. At the same time the care boulevard acquires income for the hospital and can be used as a tool to connect the hospital to its surrounding environment. 36 Because hospitals were still getting bigger, architects searched for new ways to make the buildings more flexible. Instead of the ‘tree like’ open-ended structures, the focus shifted towards architecture that organized different functions within one big unified structure, like in airports. Clusters of specialties with corresponding facilities were placed inside the big structure and starts are being made with hospital models in which the medical specialist would come to the patient instead of the other way round. An example of this is the new Maasland hospital in Sittard which will be elaborated on in the last chapter.

By additionally incorporating technical developments, the idea of a core hospital

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met a lot of approval. This hospital concept pursues the disposing of lighter forms of healthcare to other locations like ‘zotels,’ separate wards, or in cooperation with home care organisations. The hospital itself would only consist of high-tech diagnostic and operational facilities which form the core business of the hospital. 37 The ‘core hospital will also be elaborated on in the last chapter. 38 Since the beginning of the new millennium, marketing mechanisms are finding their way in the healthcare system more than ever. Healthcare institutions have become responsible for their own real estate and therefore need to find new formulas to finance construction and exploitation costs. More than ever it became important to construct flexible, effective and marketingattractive buildings. But in contrast to the big architecturally neutral structures of the eighties, the hospitals are now designed for the empowerment of the patient. The better the hospital looks, feels and functions, the

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37.

Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008. (describes architectural research on ‘zorg hotels’)

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more patients or rather clients, it will attract.

Instead of regulating the offer, cost-reduction is realized by opening up market competition by which the offer is regulated by its demand. 39 It can be argued if in the end patients really benefit from the marketing strategies or that it just puts more pressure on the patient and divides the patients in terms of rich and poor. Nevertheless, the re-found focus on the patients gives the architect and the interior architect the important role and opportunity to be creative and find new ways to make the buildings attractive and at the same time keep the costs low.

38.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 234-238.

39.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 277-285.

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2. New approaches within healthcare and healthcare architecture As discussed in the last chapter, the ideal of humanizing healthcare originated in the seventies as a counter reaction to the clinical, inhumane and systemized field of the healthcare institutes. Because the focus was still more on expansion and flexibility, a real break concerning ‘philanthropic healthcare’ only originated in the nineties.

In contrast to the eighties with its big open-ended hospital structures, which caused the architect to be manipulated by the building rather than the other way round, the nineties brought new possibilities to be innovative. The new approach toward effectiveness referred back to the never reached ideals of the seventies. The focus on the patient challenged both medical professionals and healthcare architects. The different (or similar) ways of trying to reach the new ideals will successively be discussed in this chapter.

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Thinking about the reorganization of healthcare, fuelled by marketing dynamics and hospital-merges, occurred inside the walls of the healthcare institute in terms of organization and practice. Instead of solely focusing on reducing costs and intensifying medical processes, philanthropic approaches were being formulated which paved the way for effective patient focused care and saving money. A well known independent foundation that disseminates ‘people-oriented care’ goes by the name ‘Planetree.’ The Dutch version was established in the Netherlands in 2003 but worldwide the foundation connects over one hundred sixty healthcare institutes in the United States, Canada, Japan, Brazil and the Netherlands. Planetree offers specific parameters, methodologies and concrete approaches in the areas: ‘better care’, ‘healing environment’ and ‘healthy organization,’ to reach and measure a people-oriented healthcare environment. ‘Only organizations that cooperate with ‘Stichting Planetree Nederland’ can use the network, name, logo, model, training, focus groups and other sources.’ 1

1. www.planetree.nl (last entered: 07-06-2012)

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2.1. Philanthropic healthcare ’Lief ziekenhuis’

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insights on how to make healthcare more patient-oriented and therefore more effective. The campaign involves everyone in the hospital, from cleaning staff to management board, and tries to structurally change the ruling culture within the hospital. The title ‘Lief Ziekenhuis’ was deliberately chosen to provoke a discussion based on care ethics within the medical field concerning the fundamental theories of the campaign.

Referring to the campaign booklet, the founders of the campaign explain the fundamentals of the campaign as follows: Like other studies in ethics, the fundaments of care ethics are based upon human action and questions about if and how these actions can be justified. By looking at care as a process, a practice, and imbedded in a relation, we can better understand the implications concerning care-ethics. In that respect the campaign pursues the dynamic approach of Bury by which the combination of the attributive and the relational perception of health accomplish a ‘sociology of the

There are also initiatives coming from within the Dutch hospitals. In this chapter I will take the campaign ‘Lief Ziekenhuis,’ translated as ‘sweet hospital,’ which is currently running in the Elisabeth Hospital in Tilburg, as an example. This chapter will discuss the structure of the campaign and its attempt to implement philanthropic healthcare within the Elisabeth Hospital.

2.1.1. Program of the campaign – care ethics The campaign in which hospital employees and care-ethicists of Tilburg University work together, started in 2009 and will come to an end in 2014 when the Elisabeth hopes to have become the ‘sweetest’ hospital in the Netherlands. By doing active research, organizing workshops and symposia, and stimulating changes on an organizational level, the aim is to gain new 438

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embodiment’ (rather than a ‘sociology of the body’) by focusing on the patient experience.

In addition, reconsidering care as a process implicates that care began somewhere, because ‘to take care, someone should first care.’ Taking responsibility and successively taking action means that certain skills are needed for competent care.

Care as a practice touches upon the organization of care and draws on the professionalism and experience of its practitioners.

Within this practice, patients, professionals and others commit to a relationship in which complications have to be overcome. ‘Professional healthcare is a specialization of something more general: people taking care of each other.’ 1 Inspired by care ethics, the campaign is divided into three main pillars: ‘anders kijken’ , ’anders doen’ and ‘anders leren’ which can be translated as ‘look, act, and learn differently.’ I will successively elaborate on these three pillars.

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2.1.2. ‘Anders kijken’ - patient experience ‘Anders kijken’ focuses on a different way of looking towards care. It is based on the consideration that by looking through the eyes of their patients, medical practitioners can get a better understanding of what it is to be sick and to be admitted into the hospital. Experiences by doctors who became ill helped to change the way in which we look at hospitals. Concluding from their stories it seemed to be a paradox that patients and illnesses within the hospital are in a way secluded from normal life when the patient’s biggest concern is to regain a grip over his life. For the patient, disease is mainly a disruption of life, time, and everything that seemed so obvious before.

One of the mentioned doctors of the Elisabeth hospital explains that during his treatment he felt as though his body was being colonized by doctors when he was still trying to grasp what was happening to him.

In a way the sick person has to reconcile with what is medically expected of him.

1.

Carlo Leget and Gert Olthuis, ‘Inleiding: het Menslievende ‘Benkske’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 12-14.

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The mental wellbeing of a patient is in large part influenced by the mentality of the caretaker, which means the patient is not the same person as he or she is in daily life.

Therefore, the ‘Anders kijken’-pillar draws largely on patient experience, which became of great importance in healthcare policy decisions in the last decades, as Bury also emphasised. A common method within healthcare institutes to map patient experience is to gather feedback by means of the Consumer Quality Index; a research questionnaire for patients. Because the research is standardized it ‘assesses its ability to measure differences between hospitals in patients’ experiences with quality of care.’ 2 Because this index only gives an impression of the average experience of several patients, an ethnographic observation research was set up in addition which could map the individual patient experiences inside the Emergency department of the Elisabeth hospital. The result points at numerous problems or rather ‘tasks’

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2. http://www. biomedcentral. com/14712415/7/14 (last entered: 14-05-2012)

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(‘Opgaves’) the patient struggles with during their admittance time. The tasks differ from ‘not being able to get to work that day’ to ‘feeling ashamed to go to the toilet in hospital rugs.’ The research concludes that the tasks are not just about the illness itself. The combination of different tasks influences the patient experience. The tasks observed in over fifty patients’ admittances are defined by four general characteristics:

3.

Gert Olthuis, Carolien Prins, Harm van der Pas and Andries Baarts, ‘Anders Kijken naar Kwaliteit van Zorg op de Spoedeisende Hulp’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 34.

1.‘Tasks point at a difficulty and are about things that do not run smoothly.

2. Tasks have a personal character and are not about what patients have to overcome in general; they are

about individual

patients at a specific moment in a certain context.

3. Tasks are inescapable and force themselves upon the patient.

Patients cannot ignore or skip their tasks.

4. Dealing with tasks demands effort and work from the patient: courage, improvisation, patience, self conquest, etc.’ 3

One hundred thirty-four tasks were found in eight analyzed cases by a team of observers. From there, they were categorized into five groups: ‘concern’ about the reliability of the caretakers and about what 442

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is wrong with them; ‘expectations’ about what is happening to them; ‘hospital care’: about repeating their story several times and about undergoing the treatment or research; and ‘enduring and bearing’ things like the suffering of your beloved, irritations of your partner, or waiting times during the stay. The last tasks are categorized under ‘recognition’ which includes the need to be heard and taken seriously. 4 Through this research, we can see that quality of healthcare is not based on generalized scientific information where patients put marks on a questionnaire, but on situational information where the relation between the patient and the caregiver constantly functions as the primary target point. 5 It occurs that misconceptions between the patient and caregiver appear because of different interpretations. Even though not labelling what is heard and seen can be very difficult, especially in the medical field, it is important that the caregiver has an open perception and keeps asking questions.

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4.

Gert Olthuis, Carolien Prins, Harm van der Pas and Andries Baarts, ‘ Anders Kijken naar Kwaliteit van Zorg op de Spoedeisende Hulp’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 34.

5.

Gert Olthuis, Carolien Prins, Harm van der Pas and Andries Baarts, ‘Anders Kijken naar Kwaliteit van Zorg op de Spoedeisende Hulp’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St.

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Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 36.

6.

Nurses frequently deal with the completion of systems like EVD, Theriak, incident melding and financial systems.

Frans Vosman, ’Te Dicht op de Diamant zie je Geen Schittering.

Open Brief aan een Verpleegkundige.’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 52.

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2.1.3. ‘Anders doen’ - changing policy The second pillar, ‘Anders doen,’ is about the concrete changes that can be made to obtain a patient- oriented, philanthropic environment. This pillar focuses for a significant part on the nurses that stand closest to the patient, but it is emphasized that it also touches upon all other executive levels within the hospital.

For the campaign, Frans Vosman, Professor in care-ethics, wrote a letter to a nurse in which he emphasized the impact of the way a nurse treats a patient on the patient experience during his admittance time in the hospital. The letter points at the way the nurse deals with systemized pressure from above and still takes time to drink a cup of tea. It disseminates that we can only truly care for someone else if we take good care of ourselves. Vosman argues for a grander recognition of the nurse’s patientknowledge within the construction of hospital policy and comments on the thirty percent of their working hours being spent on the completion of diverse systems. 6

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Vosman is also critical of the up rise of marketing strategies and the decrease in governmental regulation.

According to him it will cause healthcare to focus solely on care that generates profit and to leaving non-profitable healthcare behind for smaller groups. Marketing strategies can cause patients to act as customers and are therefore increasingly critical towards the provided healthcare. He argues that nurses, who know the real patient in contrast to the client version, should also be involved in the debate around marketing strategies within healthcare.

2.1.4. ‘Anders leren’ – making structural changes The third and last pillar ‘anders leren’ elaborates further on the cooperation between nurses and doctors and is about structurally changing the ruling care-culture.

Because care is considered a relation between several persons with or without an emotional connection, emotions along with

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7.

Eric van Elst en Andries Baart, ‘Hoezo Implementeren? Anders Leren!’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 79.

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knowledge are suggested as a valuable source in decision making. 7 Andries Baart, extraordinary Professor Presence and Care, 8 explains how thinking in terms of care ethics can benefit the learning process of professional caregivers by the following model which he calls ‘the care-ethical learning house’ (‘Zorgethisch leerhuis’). This model, used as a guideline within the ‘Communities of Practice,’ is actually a theorization of all the above mentioned indications.

The notions in the model on the next page can be explained as followed: ‘Normative’ means the recognition that every health service consists of making ethical decisions.’ It asks questions like’ What is good care?’ and ‘What is a good caretaker?’

‘Reflective’ means the creation of a certain distance between protocols, generalities, uncritical and thoughtless compliance and obedience.’

8.

The ‘Presentie theorie’ is another approach which is also used in elderly and psycho geriatric care. This approach is about leaving rules behind and focus on what the individual patient needs.

Andries Baart writes extensively about this notion.

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‘Professional’ refers to giving care of high quality and competence.’ The professional is always able to justify his actions.9 The five pillars successively stand for ‘activities for stimulating the development of individuals in group training,’ ‘learning on a deep and personal level,’ ’defining tacit knowledge characterized by implicit and personal, craft-knowledge,10 ’ ’professional identity formation through case-based learning, changing of perspectives, and researching their own practices’ and ’integration of practice, research and creation.’ The base is formed by ‘relational plurality,’ an important care-ethical principle which means that within the Community of Practice, the professionals learn about themselves in relation to their colleagues, other disciplines, patients and the organization.11 With the ‘Care- Ethical Learning House’ the campaign touches upon the shifting patient-doctor relation as a result of care-consumerism and new media, as Bury also described. The campaign booklet refers

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9.

Eric van Elst en Andries Baart, ‘Hoezo Implementeren? Anders Leren!’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 83.

10.

Tacit knowledge is described

by Polanyi (1966) and can be understood as implicit knowledge that is obtained through experience.

Eric van Elst en Andries Baart, ‘Hoezo Implementeren? Anders Leren!’ in Gert Olthuis and Carlo Leget, Menslievende

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Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 83.

11.

Eric van Elst en Andries Baart, ‘Hoezo Implementeren? Anders Leren!’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 80-87

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Eric van Elst and Andries Baart, Care-ethical learning house.

Source: Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 81.

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to the statement that ‘a good health relation is an equal relation between unequal parties’ by the ‘Raad voor Volksgezondheid en Zorg’ in 2009, which claims that ‘a non realistic expectation pattern of the patient can hinder a good patient-doctor relation and finds its roots in a changing healthcare system and shifting social conceptions about care.’ 12 In addition, the ‘rising systemized pressure on doctors to reduce costs and increase productivity, leaves less time for the patient.13 Seven areas of competence based on compassion, courtesy and skill that are decisive for competent medical operating are cited from the ‘Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst’: ‘Apart from being a clinician, the doctor also has the role of communicator, collaborator, scientist, health advocate, manager and professional.’ 14 The campaign booklet also mentions the ‘Opleidings- en Onderzoekscentrum’ (Education and Research-centre) which practices a slightly different approach

Naomi Cheung San

12.

Gert Olthuis, Leo Visser and Bart van de Langerijt, ‘Van Lastige Patiënten naar Goede Patiëntenzorg’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 101.

13.

Gert Olthuis, Leo Visser and Bart van de Langerijt, ‘Van Lastige Patiënten naar Goede Patiëntenzorg’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 101.

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14.

Gert Olthuis, Leo Visser and Bart van de Langerijt, ‘Van Lastige Patiënten naar Goede Patiëntenzorg’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 102.

15.

Jack van de Langenberg, ‘Anders Leren Omgaan met Patiënten?’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 105.

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than that of the ‘Care-Ethical learning House.’ Referring to research by Kwakman in 2002, the ‘Opleidings- en Onderzoekscentrum’ argues that a supply-driven training policy which is structural is preferred over a demand-driven policy which is incidental.

The former is claimed to be more preventive of character. The ‘Opleidings- en Onderzoekscentrum’ provides a structural communication-training program in which the demands and the level are gradually raised.’ 15 2.1.5. Reflecting on the program Having discussed the three pillars of the campaign, it becomes clear how the Elisabeth hospital attempts to implement a philanthropic care-culture based upon situational information rather than generalized, scientifically derived information. The last example proves it is still not certain which is the best approach, and for example whether it is necessary to put ‘looking differently’ before or after ‘learning and acting differently’. 16 ‘Theoretically it is not entirely clear how

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Jack van de Langenberg, Longitudinaal trainen van communicatievaardigheden.

Schematic visualisation of the communication training program of the ‘Opleidings- en Onderzoekscentrum.’

Source: Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk. Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 106.

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16.

Jack van de Langenberg, ‘Anders Leren Omgaan met Patiënten?’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 108.

17.

Jan den Bakker, ‘Lief Ziekenhuis.

Het Ontstaan en Invoeren van een Programma tot Verandering.’ In Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 75.

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18.

Jan den Bakker, ‘Lief Ziekenhuis.

Het Ontstaan en Invoeren van een Programma tot Verandering.’ In Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 73.

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the programs substantially relate to each other.’ 17 Difficulties in measuring the effectiveness of philanthropic approaches establish this. Indicators like ‘the increase of compliments, decrease of complaints, becoming more attractive on the labour market, less elapse of staff and a better reputation in a general sense’ ‘do not say a lot about cause/ effect relations’ which is confirmed by founders of the campaign.’’ In the end it is about a culture in which reflection and dialogue are self-evident and that puts the quality of experience by patients and the joy of working by the caregivers on the first spot.’ 18 By fixing the rules it does not necessarily mean that care is instantly humanized. Real results are not easily measured when the focus is on relational guiding between patient and caregiver.

In addition, the effectiveness of some of the practical approaches is questionable. For example the ‘Klant is Koning’ course which currently runs within the Elisabeth hospital, seems to lack the

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effectiveness and ethical-theoretical profundity of the ‘Care-Ethical learning House’ since it mainly focuses on how to act. The rather holistic nature of the course might not be very tempting for clinically grounded specialists.19 Other criticism comes from Margo Trappenburg. According to her there is a risk of ‘overdoing’ philanthropy. She points at the ideals of transparency and measurability in healthcare of the eighties and nineties, which caused the medical world to constantly attempt to catch up with quality indicators by healthcare insurers, and demanded that patient interest groups become better, faster and more efficient. According to her, focusing on patient empowerment and demand could turn the hospital into a shop that creates needs, or a luxury hotel that provides rooms in different price ranges, causing inequalities between patients. In addition, philanthropic approaches deny the benefits of ‘professional distance’ which the medical practitioner may need in order to

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19.

Lieke van de Wouw, Sietse de Vries and Renske Hermus, ‘KiK: Klant is Koning. Maar hoe doe je dat als Team?’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 6368.

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20.

Margo Trappenburg, Lief Ziekenhuis: De valkuilen, Voordracht voor het symposium Lief ziekenhuis, 2012. www.liefziekenhuis. nl/upload/ userfiles/ File/Lief%20 ziekenhuis%20 lezing%20tilburg%2022%20 maarttrappenburg.pdf (last entered 08-06-2012) 21.

Margo Trappenburg, Genoeg is Genoeg. Over Gezondheidszorg en Politiek, Amsterdam: University Press, 2008.

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do his job properly. 20 In her book ‘Genoeg is Genoeg’ Trappenburg elaborates on the negative side effects of democratization of care for the patient after recognizing the numerous responsibilities he gained in his observation of new patient-doctor models and the rise of patient interest groups.21 Although the patient oriented approach in the Elisabeth hospital seems promising, it is wise to keep situating healthcare in a bigger context when pursuing the adjustment of healthcare policies. By keeping in mind both the positive and negative implications of the healthcare institute the risk of ‘overdoing’ philanthropy can be diverted.

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2.2. The Healing Environment It is remarkable that the ‘Lief ziekenhuis’ campaign often touches upon indications of the physical environment but that they are not really recognized as such.

Within the campaign, consequences of the physical environment are discussed as implications of a certain policy or of individual initiatives.

An example of this is the suggestion by aesthesia employee Peter van Dun connected to the pillar ‘acting differently’ to initiate the implementation of a sound system in every anaesthesia station. Van Dun discovered the positive, relaxing effect of playing a patient’s favourite music, right before they undergo anaesthesia. It made him aware of the patient’s own strengths, but emphasised the difficulty he had in convincing his colleagues of the positive effects of this extra operation.1

1.

Wim Pleunis, ‘Slaapmuziek. De Kracht van Muziek op de operatiekamer.’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktij.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 59-62

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2.

Judith Baselmans, Marieke Willems, Marieke Faro, Judith Martens and Gert Olthuis, ‘Menslievende Zorg aan de Balie’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 95-98..

3.

Gert Olthuis and Carlo Leget, ‘De Leefwereld van Patienten’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 22.

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In addition, another research done on the structural commotion at the counter of the nursing department for oncologic patients in the Elisabeth Hospital also points at the environmental factor ‘sound’ or rather ‘accoustics’, an environmental factor which is also important for the Healing Environment as we will find later on. 2 A second example of the importance of the environment is the remark by medical sociologist Arthur Frank (1992) who suffered from a heart attack and testicular 1 cancer, that ‘hospitals neutralize the senses; once outside I became aware of the fresh air, colours and structures, changes of light and the sound of the normal world.’ 3 Normalization in terms of the environment is an important topic of the Healing Environment .

Another topic that touches upon healthcare architecture is that of ‘decentralization’ and the wish to bring healthcare closer to the patient, which is mentioned by Professor of Care-Ethics; Frans Vosman in his letter to a nurse.

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The final environmental consequence that I would like to bring forward from the ‘Lief ziekenhuis’ campaign regards the change of policy in the oncology department of the hospital which suggested to first knock on the door before entering a patient’s room. If the patient considers the room his private domain it can have a positive influence on his perception of the hospital, his illness, and eventually on his healing process.4 All of the above changes whether big or small, validate the importance of the environment for the healing process and could all be related to the concept of the Healing Environment. Where human actions cannot so easily be changed by adjusting policies or implementing ‘patient oriented courses’, it seems that manipulating or rather stimulating different behaviour by changing environmental factors, whether physical or not, could be more effective. Last decades have been characterized by a shift in healthcare architecture from function on

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4.

Astrid Mikkers, ‘Leren in een Lerende Gemeenschap; in Gesprek met de deelnemers’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 89-93.

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5.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 9.

Kirk Hamilton, ‘Evidence Based Design and the Art of Healing’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 271.

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to the experience of the people inside the buildings.

In this respect the Healing Environment is one of the most talked about concepts. Even though the significance of the Healing Environment is often undermined by journalists and architects that use the term too casually or by critics that presume the only solutions it applies consists of adding plants and windows, the concept initially focuses on both: the ‘creation of an environment to accommodate the medical processes inside that focus on healing the individual’ and the creation of an environment that directly stimulates the healing process of the individual. 5 This chapter will successively discuss the relation between the essence of architecture and the Healing Environment, the up rise and meaning of the concept, its implementation in Dutch healthcare architecture, and its complicated relation with Evidence Based Design.

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2.2.1. The essence of architecture When questioning how architecture can contribute to healing, it touches on the essence of architecture. ‘Even though design is architectures core business, it has far more fundamental issues to solve than the visual appearance of buildings.’ 6 While doubts have been raised before about the alleged influence architecture has on peoples wellbeing due to its material or instrumental character, the impact of the environment nowadays is widely recognized and architectural projects are critically valued by its social relevance and ‘embeddedness’. 7 Every architect has to find its own way in dealing with the responsibility towards society which can be quite challenging. In his ‘Architecture in the Age of the Divided Representation,’(2004) Dalibor Vesely points at the gap between the creative personal vision and the abstract, instrumental systems within the architectural process of creation and presupposes closing this gap by arguing that ‘the goal of archi-

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6.

Agnes van den Berg and Cor Wagenaar, ‘Healing by Architecture’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p.

254.

7. Alain de Botton, The Architecture of Happiness.

The Secret Art of Furnishing your Life, London: Penguin Books, 2007. http:// programma. vpro.nl/ deslagomnederland/ meldingen/ lelijksteplekvannederland-speellijst.html (last entered 25-05-2012) A current example of urban planners having to be accountable for their actions is the election for

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the ugliest place in Holland held by the VPROtelevision program Slag om Nederland in May 2012. Over ten thousand viewers voted. The design of the nominated places become the subject of a heated discussion on the belonging website.

8.

Dalibor Vesely, Architecture in the age of the Divided Representation. The Question of Creativity in the Shadow of Production, London: The Mit Press, 2004, p. 5.

9.

Dalibor Vesely, Architecture in the Age of the Divided Representation. he Question

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tecture is human life, while its techniques and instrumental thinking are only means.’ 8 Vesely argues for a restoration of the ‘communicative role’ and with that the ‘humanistic nature’ of architecture. 9 In his opinion: ‘Architecture can make its main contribution by creating conditions that support a different experience, a different way of life, and perhaps even a different way of thinking about the nature of our expectations.’10 Since it directly influences the life of individuals and society as a whole, healthcare is socially embedded in principle. In order to stay on top of the game, healthcare practitioners and policy makers should constantly be asking: ‘What is the best strategy to improve someone’s health?’ 11 ‘Architects have all been educated to understand that the physical environment influences human activity and behaviour, so the idea of an environment influencing health is readily supported by designers.’ 12 Subsequently, from an architectural angle, the answer to the previous question focuses on the physi-

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cal environment rather than on the individual itself. Therefore that ‘humanistic nature’ of which Vesely speaks is especially important in healthcare architecture. The individual can be reached through the environment and therefore the environment (supposedly) heals indirectly.

The way architecture influences the individual is not always measurable, but according to Alain de Botton (2007) it should at least reflect the ideals we try to pursue through the architecture: ‘any object of design will give off an impression of the psychological and moral attitudes it supports.’ ’In essence, what works of design and architecture talk to us about is the kind of life that would most appropriately unfold within and around them.’ 13 In that respect, the way we design our healthcare institutes can be considered as a tangible translation of our perception of healthcare, sickness and health.14 It is therefore important to analyse philanthropic initiatives from within the hospital like ’Lief Ziekenhuis’, next to philanthropic

of Creativity in the Shadow of Production, London: The Mit Press, 2004, p. 6.

10.

Dalibor Vesely, Architecture in the Age of the Divided Representation. The Question of Creativity in the Shadow of Production, London: The Mit Press, 2004, p. 7.

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(ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 271 13.

Alain de Botton, The Architecture of Happiness.

The Secret Art of Furnishing your Life, London: Penguin Books, 2007, p. 72.

11.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 8.

14.

Alain de Botton, The Architecture of Happiness.

The Secret Art of Furnishing your Life, London: Penguin Books, 2007, p. 73.

12.

Kirk Hamilton, ‘Evidense Based Design and the Art of Healing’ in Cor Wagenaar

15.

Agnes van den berg and Cor Wagenaar, ‘Healing by Architecture’ in Cor Wagenaar (ed.), The Archi-

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approaches from the architectural field such as the Healing Environment to find out how they could benefit from each other.

2.2.2. Framing the Healing Environment In the introduction I pointed out how the importance of the environment for our sense of wellbeing or rather, our health perception, is valued through history. The theme of the Healing Environment can be traced back to the late-eighteenth century when it became generally accepted that the designed environment contributes to the healing of patients. During the Enlightenment ‘a natural setting and the provision of clean air were essential.’ 15 It is exactly that connection to the natural setting and therefore regarding as a patient as a whole being, body and soul, which is pursued by the Healing Environment. With its research into nature, options and choices, positive distractions, access to social support and environmental stress factors, the Healing Environment is a counter reaction to the clinical,

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impersonal and even inhumane environment of the healthcare institutes.16 The term ‘Healing Environment’ originated in the United States as an indirect result of groundbreaking research done

by Roger S. Ulrich in 1984 as mentioned in the introduction. Ulrich, who is connected to ‘The Center of Health Design’, is seen as one of the founders of this new approach.

Today, many medical researchers utilizing nature distraction in pain reduction cite his window view study as a starting point. However, studies today are quite different since procedures of treatments have changed and patients spend less time in the hospital.17 The scientific base underlying the concept points out the most revolutionary aspect of the Healing Environment compared to other architectural concepts: ‘Design professionals have begun to use evidence from the clinical sciences and behavioural sciences.’18 Because the concept is grounded in the behavioural sciences such as environmental psychology rather than architecture it

Naomi Cheung San

tecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 254-257 16 Jain Malkin, ‘Healing Environment as the Century Mark: the Quest for Optimal Patient Experiences’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 259.

17 http://www. healthcare design magazine. com/article/ conversationroger-ulrich? page=2&com_ silverpop_ iMA_page_ visit_%2 Farticle%2 Fconversation -roger -ulrich=1 (last entered 25-05-2012)

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Interview with Roger Ulrich.

18.

Kirk Hamilton, ‘Evidense Based Design and the Art of Healing’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 275.

19.

Juhani Pallasmaa, The Eyes of the Skin: Architecture and the Senses, Chichester: Academy Press, 2005.

The significance of the human senses is also recognized by Dutch authorities that ensure the feeling of safety in public spaces.

Furthermore, many issues discussed in

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is important to analyze it from multiple angles. Different semiotic explanations of the term ‘environment’ point to a deeper layer of the concept, and presuppose that the concept can be applied on different architectural layers and scales with different implications to deal with. On the one hand ‘environment’ can be read as the static environment, which consists of spaces, organization, materiality and lighting. On the other hand the ´Healing Environment´ focuses on dynamic factors concerning the surrounding people and the way they act in terms of logistics and routing. Evidently, like environmental psychology, the Healing Environment covers both explanations of ´environment.´ Within this realm of thoughts the Healing Environment borrows many environmental characteristics of ‘haptic architecture’ which pursues the design of spaces adjusted to the human scale by taking into account all of the human senses and the relations between them.19 As discussed in chapter 1.1., Bury argues that better living standards and longer

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life expectancy are ascribable to environmental factors rather than the improvement of medical science. ‘While medical science mainly focuses on fighting immediate problems, the emphasis of designing for ‘healthy environments’ is mostly on prevention.’ 20 This stresses a second semiotic ambiguity.

The term ‘healing’ presupposes the ability to heal sickness. Kirk Hamilton (2006) recalls that ‘Calling something a healing environment is meaningless unless we can answer two questions: 1) who was healed?

And 2) how do we know? Through scientific research, under the umbrella of Evidence Based Design which will be addressed to later on, ‘the Healing Environment proved to have a positive effect on health indicators like fear, blood pressure, recovery after surgery, use of medication and admittance time.’ 21 Here, the definitions of sickness and health should be regarded as ambiguous taking in account that an environment would not likely heal a broken leg but could still have a positive effect on the healing process

Naomi Cheung San

the ‘Lief iekenhuis’ campaign focus on the senses.

Marnix Eysink Smeets, Koen van ’t Hof and Anke van der Hooft, Multisensory Safety: Zintuigbeïnvloeding in de Veiligheidszorg.

Een Verkenning van de Mogelijkheden, Utrecht: Centrum voor Criminaliteitspreventie en Veiligheid, Hogeschool INHolland and the Police Academy, 2010.

20 Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 8.

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21 Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 32 22.

The different spatial organization also had to do with the emergence of care boulevards in order soften the border between outside and inside and at the same time make some profit.

Karen Heijne, ‘Zorgboulevards. EGM Architecten’, Architectenweb Magazine, 45, 2011, p. 54-59.

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by reducing stress factors and optimizing medical processes. Therefore, the focus of the Healing Environment mainly lies on stress reduction.

2.2.3. The Healing Environment in the Netherlands The Healing Environment became especially popular in the Netherlands during the second half of the nineties, when numerous Dutch hospitals started to work on renovation plans due to lack of space and outdated spatial organization.22 Seizing the opportunity, the Healing Environment provided a way to do away with the impersonal, clinical atmosphere of the hospital.

Research concerning the Healing Environment in the Netherlands is mainly executed by ‘Stichting Architectenonderzoek Gebouwen Gezondheidszorg’ (STAGG) in cooperation with technical universities, architectural historians, or by researchers from the field of environmental psychology, like Agnes van den Berg.23

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While in the United States the priority lies in ‘patient safety’ in terms of ‘reducing infection,’ ‘reducing medical errors’ and ‘reducing patient falls,’ which can be connected to Evidence Based Design rather than the Healing Environment, in the Netherlands the focus is more on stressreducing factors like ‘effects of nature distraction on pain,’ ’effects of daylight exposure on pain,’ ’improving patients sleep,’ ’reducing depression,’ ‘reducing length of stay,’ ’reducing spatial disorientation,’ ’improving patients privacy and confidentiality,’ ’fostering social support’ and ’increasing staff effectiveness.’ 24 Noor Mens and Cor Wagenaar (2009) who can be regarded as authorities in the field of Dutch healthcare architecture give a clear description of what the Healing Environment entails for architects: ‘all spatial abilities in healthcare architecture should be attuned to each other: use of materials, colour, acoustics, lighting, air control, view, disclosure, facilitation of contact between the

23.

On the first of January 2012 Agnes van den Berg was appointed extraordinary Professor ‘Beleving en waardering van natuur en landschap’ at the faculty Spatial Sciences of State University Groningen.

The Healing Environment Reconsidered

26.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 23.

24.

Roger S. Ulrich (ed.), A Review of the Research Literature on EvidenceBased Healthcare Design, Georgia: Institute of Technology, 2008.

25.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 9-10.

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users and receiving visitors from the outside, routing and signage, division in multiple small buildings or combining functions in a concentrated building-volume, and the relation either way to the city or to a more natural setting.’ 25 ‘For specifying the value of an environments ‘healing’ opportunities, the whether or not measurable experiences of patients and staff in terms of health outcomes, stress, amount of complaints during and after the stay, are determinative.’ 26 In order to get some clarity in the somewhat blurry field of the Healing Environment, Karen Dijkstra (2009) cited by Noor Mens and Cor Wagenaar formulated a list which identifies several ‘environmental’ (in the broader definition of the term) elements that are important for determining the healing qualities of an environment:

The Healing Environment Reconsidered

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Reception The reception is important for the way you enter the building.

It requires clarity and a certain amount of privacy. The reception should be recognizable and connect to the internal logistic structure of the hospital.

Orientation Not knowing where you are is experienced as being stressful and further strengthens the feeling of isolation and neglect.

The right signage and organisation of different departments is crucial.

Waiting In hospitals, a lot of time is spent on waiting. Differentiation, view and distraction are important notions for bridging waiting times.

View The quality of a patient room is mostly determined by its view.

Roger S. Ulrich proved that a green view improves the healing process.

Green Installing patios and providing public spaces with plants or even pictures of nature can have a positive effect on the experience.27 Materialisation Cheap materials can suggest that the hospital is not interested in welcoming the patient. ‘Sustainable materials have the opposite effect and are often cheaper.’

Social support Support by friends and family is important when you are ill.

Naomi Cheung San

27.

Agnes van den Berg and Marijke van WinsumWestra, Ontwerpen met Groen voor de Gezondheid.

Richtlijnen in de Toepassing van Groen in ‘Healing Environments’, Wageningen: Alterra, 2006.

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30 Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 23-24.

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The public space and patients’ rooms of the hospital should provide a certain amount of privacy to receive visitors.

Normalisation ‘Hospitals isolate a part of life from society and accommodate this under a kind of machinery with its own regime. This isolation that is connected to the institutionalisation of society is generally seen as negative: it would be better to dissolve borders between hospital and society for as much as possible..’28 Privacy The experience of illness is very personal and this contrasts with the collective, impersonal character of the medical company.

Decreasing boredom Activities, television but also spatial differentiation can

28.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 23.

decrease boredom.

Empowerment It is impossible to adjust the environment to every individual but it can be conducive to a sense of wellbeing to give the patient the ability to personalize his room with paintings or posters.

29 http://www. martiniziekenhuis.nl/ Over-Martini/ ZorgvisieMartiniZiekenhuis/ HealingEnvironment/ (last entered: 25-052012)

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Colour A lot of research has been done on the psychological effects of certain colours. For example: the ‘Martini Hospital’ contains a combination of eighteen colours from the colour-palette that artist Peter Struycken specially designed for the renovation.29 Acoustics Sound pollution cannot only increase the level of stress, it can also compromise privacy.30

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The Healing Environment Reconsidered

Among these environmental elements, the terms ‘normalisation’ and ‘the support of self-identity’ are important notions for health perception that were also elaborated on by Bury. According to guidelines belonging to the Healing Environment, working towards ‘normalisation’ of the healthcare institute and ‘the support of self-identity’ of the patient can be reached by focusing on ‘patient empowerment’, ‘privacy’ or even ‘social support’ and ‘orientation’ when designing a environment for healthcare. The different explanations of the notion of ‘environment’ within the list above strikingly points at the suggested dynamic approach between the ‘relational’ and ‘attributive’ perception of health as described by Bury. Referring to Bury; ‘normalisation’ and ‘self identity’ are both very context-related notions and therefore cannot be reached by giving clear-cut solutions. Implications of these notions for the Healing Environment will be further discussed in the next chapter.

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Although recognizing the contextrelated nature of the Healing Environment, the checklist below, also taken from the textbook ‘Healing Environment, Anders Bouwen voor Betere Zorg’ (2009) is another attempt to give architects some concrete guidelines for designing a Healing Environment. The list can be seen as a practical, concrete translation to the former list of environmental factors.

2.2.4. Evidence Based Design and the Healing Environment In the nineties, ‘activities of ‘The Center for Health Design’ encouraged the up rise of a specific field, as did growth of the Healing Environments movement, which evolved later into the ‘Evidence-Based Design movement’. The research gained more momentum from the fact that mind-body medical science was developing rapidly and confirming that patient stress and emotional states affect clinical outcomes. The idea that stress-reducing 472

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interventions improve clinical outcomes has become mainstream knowledge in the education of medical students.’ 31 ‘Ulrich has identified sufficient credible research to suggest that stress reduction can be achieved by the designers understanding of social support, sense of control, and positive distraction. Each category in turn, has multiple facets.’ 32 The rise of Evidence Based Design in the United States can be seen as a result of the rising financial interests of hospitals and the competition between them.

The popular Healing Environment proves to be a great marketing strategy and the ‘evidence base’ is a great way to underline its cost reducing factors and the improvement of organizational effectiveness. The confirmation that ‘a good healing environment can limit the duration of stay and helps the staff provide care to more patients in less time’ is very appealing to business minded administrators. In addition, ’patients are more satisfied with accepted treatment

Naomi Cheung San

31. http://www. health caredesign magazine. com/ article/ conversationrogerulrich?page= 2&com _silverpop_ iMA_page_visit_%2 Farticle% 2Fconversationroger-ulrich=1 (last entered 25-05-2012) Interview with Roger Ulrich.

32.

Kirk Hamilton, ‘Evidense Based Design and the Art of Healing’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 277.

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33.

Marit Overbeek, ‘Ziekenhuis als Leefomgeving’, De Architect.

Interieur, 42, 2011, p. 39.

34 Kirk Hamilton, ‘Evidense Based Design and the Art of Healing’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 271.

35 Kirk Hamilton, ‘Evidense Based Design and the Art of Healing’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 272.

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and therefore are less inclined to sue the hospital, which is important in the United States.’ 33 Evidently this brings me back to the main question regarding the Healing Environment: Can an environment heal?

Kirk Hamilton (2006) proposes an answer by making his own definition of the Healing Environment: ‘A Healing Environment is the result of Evidence based Design that has demonstrated measurable improvements in the physical and/or psychological states of patients and/or staff, physicians, and visitors.’ 34 While the Healing Environment touches upon different fields of expertise including geography, medical science, psychiatry, psychology, sociology, and also that of marketing economy, the field of Evidence Based Design is more homogenous and refers to Evidence Based Medicine as discussed in chapter 1.1. ‘Evidence Based decision-making is especially well suited to the healthcare field, it appeals to physicians practicing on the basis of medical evidence.’35

The Healing Environment Reconsidered

New Approaches Within Healthcare and Healthcare Architecture

Naomi Cheung San

The Healing Environment Reconsidered

New Approaches Within Healthcare and Healthcare Architecture

Naomi Cheung San

Evidence Based Design pursues the gathering of scientific evidence by measuring the effects of environmental manipulations on individuals by isolating certain parameters such as views from a patient’s room. In practice it proved to be difficult to get pure test results since environmental factors like the use of material or colour have a relational connection with each other and are impossible to fully seclude from the health-experience.

According to Kirk Hamilton ‘evidence Based Designers make critical decisions, together with an informed client, on the basis of the best available information from credible research and the evaluation of completed projects.’ He sees it as the responsibility of architects that are responsible for health facility design to use the evidence.

‘If credible design can improve clinical outcomes and patient safety, and if healthcare executives are responsible for construction projects and budgets, then healthcare executives have a responsibility to select 476

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and encourage qualified architects to utilize such evidence.’ 36 It still proves to be a challenge to define health outcomes in order to validate the Healing Environment. Aside from medical results like the use of medication and the length of the hospital stay, subjective results like ‘appreciation for the medical staff and for the hospital in general,’ ‘amount of privacy,’ and ‘accommodation of social support’ are also mapped.37 Like Noor Mens and Cor Wagenaar (2009) who make the connection with the Enlightenment in the eighteenth century, Hamilton also points out that ‘Evidence Base’ implies to be something new in architecture when architecture actually always have been ‘a blend of art and science.’ ’What is different in the way the term is used today is that design professionals have begun to use evidence from the clinical science and the behavioural sciences.’38 In that respect there is also a clear distinction with Evidence Based Medicine which solely focuses on statistics and

Naomi Cheung San

36 Kirk Hamilton, ‘Evidense Based Design and the Art of Healing’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 274.

37 Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 20-21.

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38 Kirk Hamilton, ‘Evidense Based Design and the Art of Healing’ in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAi Publishers, 2006, p. 275.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 19-20.

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does not take in account patient experience.

It can be argued that approaches used in the Elisabeth Hospital like that of the ‘CareEthical Learning House’ are much more connected to Evidence Based Design than Evidence Based Medicine since the former departs from a care-ethical perspective rather than a purely scientific one.

It is exactly that assent of the relational character of the experiments and the belonging results of Evidence Based Design, that causes hesitation regarding its effects by some architects and medical practitioners. There is also a fear of extra rules from the outside since Evidence Base is not grounded in architecture but in environmental psychology. But, like critics of Evidence Based healthcare, many architects agree that solely focusing on the accommodation of healthcare processes has become outdated and they establish belief in the significance of architecture for healthcare.

The Healing Environment Reconsidered

Reconsidering the Healing Environment in Practice

Naomi Cheung San

The Healing Environment Reconsidered

Reconsidering the Healing Environment in Practice

Naomi Cheung San

3. Reconsidering the Healing Environment in practice Regarding the Healing Environment, the question changes from “Can an environment actually heal a person?” to “What is the best place for a Healing Environment?” If architecture can ‘provide an environment that supports people in coping with stress or other symptoms of illness, it is good to realize that within the hospital, notions of ‘choice’ and ‘normalization’ are always limited by the constraints of the hospital regime.1 The isolation of the hospital or the healthcare institute in general, of which Karin Dijkstra talked about in a negative sense, might not be so negative after all, since it serves to control and protect the medical field and provides the opportunity to step outside society in order to fully recover, which is especially important for stressrelated illnesses. Hospitalization or institutionalization of the patient in the negative sense of the word will be no longer relevant

due to improvements of treatments and the decreased admittance time.

In the light of these developments, the ultimate Healing Environment might not be located inside the walls of the hospital, but rather outside. Separating the ‘care’ from the hospital envisaged as the Healing Environment might even strengthen the ‘curing’ ability of the hospital which, is essentially the basic task of the hospital.

1.

Matthijs Hesta, ‘Care Hotel for Young Cancer Patients’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 31.

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3.1.‘Caught between denial and aesthetics’ Currently, the Healing Environment is a popular concept within healthcare architecture in the Netherlands. Its guidelines are followed consciously or unconsciously by many architects, often making it difficult to define to what extent the healthcare institute has really become a Healing Environment.

The different environmental factors often compromise each other and it is up to the architect how he chooses to utilize the concept in a specific situation.

Despite of what nice pictures of Healing Environments suggest, the concept is executed at its best when it challenges the architect to readily incorporate environmental characteristics of the Healing Environment when designing the functional and logistic layout for the hospital (or program) instead of adding it later on as a kind of green finish.

The Healing Environment Reconsidered

Reconsidering the Healing Environment in Practice

Naomi Cheung San

1

D/Dock, VUmc Cancercentre, Amsterdam, 2011.

Example of a Healing Environment.

1.

Christoph Grafe, ‘Ziekte en Ziekenhuizen: Tussen Ontkenning en Esthetisering’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 69-70.

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Source: http://www.dearchitect.nl/ projecten/2011/46/amsterdamd-dock-vumc-cancer-center/ vumc-cancer-center-amsterdamdoor-d-dock.html (last entered: 01-072012)

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Referring to the last chapter, notions like ‘normalization’ and ‘self-identity’ are both important as much as they are complicating for the Healing Environment, and indicate a more complex layer of the concept.

According to Karin Dijkstra (2009)‘Hospitals isolate a part of life from society and accommodate this under a kind of machinery with an own regime.’ It would be better to dissolve borders between hospital and society for as far as possible.’ 1 Architect and publicist Christoph Grafe (2008) recognizes and simultaneously contests the current tendency of healthcare architects toward pursuing the dissolving of borders between the hospital and its surroundings, and ‘the disposing of the institutional character of the hospital wherein everything points at the exceptional position of the patient.’ 2 Grafe questions if a patient is really helped by an environment that looks as ‘normal’ as possible when he, for example, finds himself in a situation where he is being told that his life

Naomi Cheung San

The Healing Environment Reconsidered

Reconsidering the Healing Environment in Practice

1 Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 23.

2.

Christoph Grafe, ‘Ziekte en Ziekenhuizen: Tussen Ontkenning en Esthetisering’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 69.

484

EGM, Architecten, Erasmus Medisch Centrum, Rotterdam, 2009.

Example of a Healing Environment.

Source: Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 27.

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is coming to an end. He criticizes the idea that the environment would really support the patient in retaining his dignity in such a moment.3 According to Grafe, ‘the denial of the crisis could be much more hurtful than the feared stigmatising effect of the traditional design of the hospitals.’

Although Grafe does not specifically mention the concept, the Healing Environment too bears ‘the risk of the softening of the harsh reality and therefore depriving us from the understanding of what is happening to us’ since it indicates a totally different environment than that of the traditional hospital.4 With this opinion he connects to visions of Margo Trappenburg as discussed before.

Naomi Cheung San

3.

Christoph Grafe, ‘Ziekte en Ziekenhuizen: Tussen Ontkenning en Esthetisering’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 69.

The Healing Environment Reconsidered

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3.2. Staging the dynamics of the hospital in a luxurious setting 1.

Noor Mens and Cor Wagenaar, Healing Environment.

Anders Bouwen voor Betere Zorg, Bussum: Thoth, 2009, p. 21-22.

4.

Christoph Grafe, ‘Ziekte en Ziekenhuizen: Tussen Ontkenning en Esthetisering’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 70.

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487

‘Business processes of hospitals are very complex. The architectural program leads to a set of functional spaces – functional in relation to business processes. The succession of intake, diagnostics and treatment necessitate ease of movement of the patient or of medical staff. If the interaction between staff and patient does not require the support of fixed, non-movable medical equipment, it is obvious that the doctor comes to the patient. If heavy technologic equipment is required, the patient must have the ability to access the place where it is located.’ 1 For Bonnema Architecten a certain vision of ‘normalisation’ resulted in the leading principle for the design of the new Maasland Hospital which is formulated as ‘the centralized position of the patient,’ a strategy that is also followed within the ‘Lief Ziekenhuis’ campaign of the Elisabeth Hospital in

The Healing Environment Reconsidered

Reconsidering the Healing Environment in Practice

Tilburg. Remarkable in its design is the ‘rigorous separation of different user groups.’ 2 Instead of organizing the hospital around medical functions, the Maasland is organized around medical processes. Different patient categories go through different treatment trajectories which results in the identification of specific groups.’ 3 Instead of defining different groups in terms of illness and disease, Margriet Bouma of Bonnema Architecten explains that the groups are defined by the ‘newly designed working-, caring- and treatment-processes that are organized ‘around the patient.’ 4 The Maasland hospital is an example of a hospital designed halfway through the nineties during the ‘construction stop’ and disseminates the radical shift from the hospital as a medical fortress to a hospital as a safe enclave. 5 ‘The architecture is luxurious but crystal clear, the materials – mainly wood – are solid but elegant, the details exceptionally tasteful. More important is the implementation of solely single rooms,’ a measure that

Naomi Cheung San

2.

Apart from the hospital space, the categorization of users into different groups or even lifestyles is also pursued within social housing and psycho geriatric care centres like in De Hogeweyk in Weesp.

3.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p.

238.

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5.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 238 6.

Promotion clip or mini-documentary: OMP Sittard Hospital of the Future Bonnema Architecten the Netherlands.wmv http://www. youtube.com/ watch?v=96GhXrAnzc (last entered 16-06-2012)

4. http://www. architectenweb.nl/aweb/ projects/ project. asp?PID=20606 (last entered 16-06-2012)

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Bonnema Architecten, Maasland Ziekenhuis as part of Orbis Medical Park in SittardGeleen, 2001-2010.

The atrium serves as the ‘connecting element’ of the hospital.

Source: http://www.zorgcentra-online. nl/actueel/Zorgcentra_ziekenhuis_van_de_21e_eeuw.html

is also encouraged by the Evidence Based Design field, and the revolutionary choice of implementing four clusters of standardized consulting-rooms, used by different doctors since the rooms are not located in separate wards. In the new Maasland Hospital the patient and the doctor meet each other at the agreed upon space. Instead of private studies, ‘there are four centres of expertise with open and flexible working spaces which stimulate physicians to share knowledge.’ 6

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The flow of patients is separated from professionals into back and front offices, and in addition a separation between the flow of clean and used goods is implemented by the use of an automatic distribution system.

For the design, Bonnema Architecten distinguished four different spaces; public spaces, meeting areas, occupational areas and working areas. ‘Each type is connected to a climate that fits the space. The atmosphere of the atrium as a public zone is linked to tropical climate. Professional zones are linked to polar climate and have a different color palette. The consulting and research rooms have a Mediterranean climate and the nursing ward has a moderate climate which is the closest to our own. The idea is that in this way the patient will feel at home more easily and will recover faster. It is this speedy recovery process that justifies the extra structural and technical quality of this hospital’ 7 Apart from ‘normalization,’ the notion of ‘identity’ also has a strong presence

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The Healing Environment Reconsidered

7.

Promotion clip or minidocumentary: OMP Sittard Hospital of the Future Bonnema Architecten the Netherlands. wmv http://www. youtube.com/ watch?v=96GhXrAnzc (last entered 16-06-2012) Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 276-285.

Naomi Cheung San

within the Maasland design and it is intrinsically connected to the notion of ‘normalization.’ In the Maasland design, a sense of ‘identity’ is implemented by giving each spatial ‘type’ its own atmosphere. Furthermore, ‘identity’ for the patient is pursued by centralizing the patient within the whole design.

Bury already confirmed the interconnectedness of ‘normalization’ and’ identity’ by arguing that ‘identity develops in human beings trough an interaction of the self and the wider society.’ 8 Architecture for public places or semi public places like the hospital always entails the tension between individual needs versus public needs. Within the concept of the Healing Environment the sense of identity is pursued by creating a certain amount of ‘self control,’ ‘empowerment’ or ‘self autonomy’ for the patient which can be practically defined as the amount of ‘choice.’

Adjacent to choice, Egbert de Warle (2008) points at the shift in terminology from ‘patients’ to ‘clients’ to ‘guests.’

8.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005, p.9.

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According to him ‘the healthcare discipline today has to deal with patients who are used to making choices,’ which is explained by Margo van Trappenburg as the rising ‘assertiveness’ of patients. But, instead of the alleged distance that Trappenburg designates by warning that the hospital should not look too much like a luxurious hotel, Warle points at the interconnectedness of the words ‘hospital’ and ‘hotel’. He argues that ‘via ‘hostel’ and ‘host’, we find the Latin hospis, hospitwhich means ‘host’ or ‘guest’. We can say that both hospitals and hotels are concerned with people staying over that receive some kind of attention. They are about hospitality.’ ’An important aspect of hospitality is to accept the patients for who they are: free individuals.’ 9 Warle then emphasises that ‘choice’ and ‘control’ are determining factors in the amount of liberty the patient has, to lay the foundations for his design of a ‘care hotel’ or ‘Zotel’: a place where patients come to recover or rehabilitate after treatment in the hospital.10

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9.

Margo Trappenburg, Genoeg is Genoeg. Over Gezondheidszorg en Politiek, Amsterdam: University Press, 2008.

10.

Birgitte Louise Hansen, ‘Onderzoek naar het Ontwerp van Zorgarchitectuur’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 7.

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11.

Birgitte Louise Hansen, ‘Onderzoek naar het Ontwerp van Zorgarchitectuur’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 7.

TU Delft dedicated one semester to the research in to the Care Hotel phenomenon.

‘A Care Hotel is a place where people come to recover or to rehabilitate after for example treatment in the hospital.’ In recent years the number of carehotels in the Netherlands have been drastically increasing.

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The rise of new building typologies like that of the Care-hotel indicates ‘processes of decentralization, liberalization and privatization of healthcare.’ 11 An interesting aspect of the Care Hotel is that it is not so much seen as a replacement of the hospital but rather as an addition.12 Instead of the design of the Maasland Hospital which tries to reform the whole organization of the hospital by making a division between front and back stage in order to let the patient feel at home, a solution is found through decentralization and the separation of cure and care.

12.

Striking about the comparison between the hospital and the hotel is the fact that the hotels ‘compete by their level of luxury and also by the amount o choice they offer. These luxuries are reflected in the number of stars of a hotel’ while the parameters used to decide on the amount of stars are similar to the way Planetree decides if a healthcare institute should be assigned to the Planetree label.

Egbert de Warle, ‘Design Considerations for Patient Choice and Control. Care Hotel for Mixed User group’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch Ontwerpen-Interieur, TU Delft, 2008, p. 55. www.planetree.com (last entered 01-07-2012)

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The Healing Environment Reconsidered

3.3. The Core Hospital, a new Healing Environment The design for ‘the hospital of the future’ that goes by the name ‘Core Hospital’ by VenhoevenCS can be seen as a step toward the new definition of the Healing Environment. The concept won the first prize in the 2004 competition opened by ‘College Bouw’ and takes into account the changing perception of healthcare. In this way, it frames the task of health architecture in a broader socio-cultural context. Venhoeven argues that the up rise of the network society and increasing environmental issues demand a new place in society. Increasing insights into the relation between mind and body, miniaturization of technology, and the correlated shorter treatment procedures in hospitals, led to the concept of the Core Hospital.

The concept of the Core Hospital proposes an efficient, compact machine that is centrally situated in the city and mainly

1.

This way of doing business is connected to the analogy of the car and air-traffic industry.

Ton Venhoeven, ‘Core Hospital’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 75.

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Ton Venhoeven, ‘Core Hospital’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 75.

Lecture by Bas Römgens of VenhoevenCS about the Core Hospital during the lecture series ‘Reset the City’ in s’Hertogenbosch 2012.

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focused on interventions in the daily and acute treatment of patients. The hospital focuses on its ‘core business’ by offering high-quality healthcare.1 The hospital only accommodates highly-necessary functions, which enables the standard hospital to be decreased by fifty percent. The smaller size of the hospital enables its integration into the city.

All remaining functions, which are often parts of the front office of the standard hospital, like physiotherapy and parts of polyclinics, will get an external accommodation. These separated functions will be connected to the Core Hospital for instance through digital connections. Therefore, geographically seen, they can be situated at large distances from the hospital. ‘In this way the Core Hospital in combination with wellness-like functions like care-hotels can contribute to the level of facilities in the daily living environment, and bring care closer to the patient.’ 2

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Venhoeven sees the up rise of marketing strategies in which the patient is seen as a client or a guest, as positive because it will restrict the power of specialists and will bring transparency and freedom of choice to the patients, which is necessary for patient empowerment.3 Venhoeven argues that ‘the best healing environment might be at home, since that is where your social network is ’ 4 but also defines the hospital as a ‘healing environment focused on diagnosis and treatment’ and proposes that extra money that comes out of the decrease of the hospital can be invested in a beautiful materialization of the architecture and the patios. In addition urban facilities like shops or a cinema can be added to the core hospital.5 Although Venhoeven admits that within their plans they want to focus more on the experience of the patient and therefore research into the ‘stress less flow’ 6 of the patient within the hospital, VenhoevenCS takes a first step in the direction of implementing the concept of the Healing Environ-

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3.

Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p.

282-283.

4.

Lecture by Bas Römgens of VenhoevenCS about the Core Hospital during the lecture series ‘Reset the City’ in s’Hertogenbosch 2012.

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6.

Lecture by Bas Römgens of VenhoevenCS about the Core Hospital during the lecture series ‘Reset the City’ in s’Hertogenbosch 2012.

Ton Venhoeven CS Architecten, Itten + Brechbuhl, prijsvraaginzending College Bouw, motto ‘Core Hospital’, 2004.

5.

Ton Venhoeven, ‘Core Hospital’ in Birgitte Louise Hansen (ed.), Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 75.

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Source: Noor Mens and Cor Wagenaar, Architectuur voor de Gezondheidszorg in Nederland, Rotterdam: NAi Publishers, 2010, p. 281.

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Conclusion

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Conclusion 1.

Eric van Elst and Andries Baart, ‘Hoezo Implementeren? Anders Leren!’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 80.

ment on a broader scale. With an eye on arguments by Grafe and Trappenburg, it can still be questioned whether the Core Hospital itself really needs to be a Healing Environment in the obvious sense of the concept.

It might be enough if the design of the hospital is solely focused on the medical processes. In that way the treatment time inside the hospital could be optimally decreased and the ultimate Healing Environment would manifest itself outside the walls of the hospital where the patients can find their social support.

2.

Eric van Elst and Andries Baart, ‘Hoezo Implementeren? Anders Leren!’ in Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk.

Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012, p. 80.

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Philanthropic concepts within healthcare and healthcare architecture like ‘Lief Ziekenhuis’ and the Healing Environment ask for a redefinition of the role that architecture can play within the medical field.

Evidently, care ethics connect to the dynamic approach proposed by Bury, by arguing that ‘the care ethical perspective treats people as relational, interdependent persons.’ 1 It favours ‘lines of thought that are situated and contextual instead of abstract reasoning with universal claims.’ 2 Within Dutch healthcare, a shift is occurring that forges ahead to the opening of the field of healthcare architecture which was, until recently, ruled by a limited number of large, specialized architecture offices.

Interior architects, artists and other external parties are playing an increasing role within the re-organisation of healthcare in the Netherlands. New visions within healthcare itself are partly responsible for increased interest in the influence of the environment on the healing process.3 Offices of architecture

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Conclusion

like that of VenhoevenCS take the lead in addressing the design of a hospital as a cultural and social challenge. They disseminate the belief that interior architecture, urban architecture, sociologists and economists should collaborate in order to bring Dutch healthcare up to date.

Philanthropic approaches like that of the Elisabeth Hospital point at the interconnectedness of strategies within healthcare and strategies within healthcarearchitecture, but also expose the separation between the fields. If the multi layered field of participants of campaigns like ‘Lief Ziekenhuis’ would join forces with healthcare architects, philanthropic approaches that often lack a certain amount of efficiently could achieve structural changes inside the hospital and also within the thinking about healthcare in our society. Looking at healthcare from an interior architectural point of view can help architects and medical professionals connect to the individual’s experience of healthcare, whether through the

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The Healing Environment Reconsidered

3.

Birgitte Louise Hansen, ‘Onderzoek naar het Ontwerp van Zorgarchitectuur’ in Birgitte Louise Hansen, Beyond Clinical Buildings, Stimuleringsfonds voor Architectuur and Architectonisch OntwerpenInterieur, TU Delft, 2008, p. 7.

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eyes of a patient, visitor, nurse or medical professional.

This brings me to the main research questions of this thesis: ‘How does the concept of the Healing Environment reflect social and cultural conceptions about healthcare?’ and ‘What changes does the practical use of the concept currently elicit in Dutch healthcare architecture?’ The Healing Environment’s main focus is stress reduction for the patient. By putting the patient at the centre of our healthcare system, the healing process of the patient could be improved and shortened. The impact of our environment on our health has a long history in which the recognition of the impact of environmental factors and of architecture as a whole was often questioned and rediscovered. Our perception of health over time fuelled different opinions in that discussion.

Bury pointed out that our changing health perception could best be explained in terms of ‘attribution,’ which regards disease as an attribute of our body, or ‘relational’ which 501

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as described in Foucault’s ‘The Birth of the Clinic’ (1973) could be further elaborated on.

The same holds for developments in elderly and psychiatric care. Approaches like’ Validation’ or ‘Reality Orientation’ are very much connected to philanthropic approaches like the ‘Presentie theorie’ or the ‘Care Ethical Learning House.’ Also implications of notions like ‘normalization’ and ‘empowerment’ could be deepened by elaborating on the important connotation of ‘liberty’ which is grounded in Dutch history. In addition, architectural concepts like routing, colour, use of green, amount of privacy and more, could all be subjects of entire theses.

Regarding the Healing Environment, it could be argued whether the title of the concept is still in place. On the one hand, like the title ‘Lief Ziekenhuis,’ it elicits interesting discussions about the role of architecture and the influence of the environment on individuals. On the other hand the term is often associated with holistic, scientifically unproved approaches, which

involves social influences. In a broader sense, the Healing Environment could best be defined as a concept that focuses on the dynamics between a ‘relational’ and an ‘attributional’ view of health. Within existing healthcare institutes the concept is mainly used to decrease the amount of stress that patients endure during their treatment, while in new architectural concepts it is used to centre all the medical processes around the patient, or even render the whole city to the benefit of the sick. In addition, the concept of the Core Hospital reflects on the Healing Environment by placing it outside the hospital. This disseminates that professional healthcare is no longer about how to seclude a sick person from society, but rather how to situate him in society in order to fully heal.

Due to lack of space this thesis leaves behind certain important issues concerning healing and the environment.

The development of the academic hospital and the emergence of the medical institution with connected hierarchical relations 502

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home as a Healing Environment over the environment of the hospital. This disseminates that besides focussing on new concepts and consequently focusing on scientific proof, it might be inspiring for architects together with health practitioners to take a look at the history of healthcare, its belonging institutes and the way it influenced perception of the Healing Environment back then.

undermines the evidence based part of the concept.

Although results of patient oriented care within a care-ethical approach, and results of the Evidence Based Design will never be clear-cut, it cannot be denied that, for instance, ethnographical research as executed in the emergency-department of the Elisabeth Hospital is an important addition to the generalized Randomized Controlled Trials connected to Evidence Based Medicine.

Architecture, especially for healthcare, continues to be a heterogeneous field that cannot be valued either by statistics or aesthetic considerations.

In essence, the Healing Environment is an attempt to make care more humane, and disease less immediate in the life of many individuals. For the future, the concept brings possibilities for the partial de-institutionalization of care. Therefore, it is remarkable that, in a way, the Healing Environment connects to ideas from the seventeenth century, when doctors preferred the 504

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From Alzheimerbus to Lijn#3210

Introduction

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From Alzheimerbus to Lijn#3210

From Alzheimerbus to Lijn#3210

Introduction

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at home in an environment that is familiar to them, which is very important for their peace of mind. Unfortunately, due to budget cuts in healthcare (for example concerning the ‘personally bound budgets’, PGB) and the implementation of Care Intensity Packages (ZZP) pressure on the shoulders of the informal caretakers is increasing. These reasons, together with the aging of our society made me decide to focus my design-research especially on unburdening homecare.

The following text can be read as a research report in which I explain and show my struggle to find the design- but also healthcare concept that could provide the best solution for Alzheimer in the near future.

If I look back on it now, I believe the main struggle was to define a clear focus. Although the idea of an Alzheimerbus came to me relatively early in the process, my attempts of making it into a concrete design made me discover different political implications and points of focus. In the end my research became not so much about the ultimate design

This project is about Alzheimer’s disease and generating a possible solution for improving the living situation and environment of Alzheimer’s patients in the near future.

To gain realistic insight in the disease and the experience of its belonging symptoms (while taking in account all the implications for Alzheimer patients as well as their caretakers) I executed research through literature, statistics and ethnographic analyses. However, it was the 48-hour internship at a psycho geriatric ward, together with interviews with (in)formal caretakers, which were most decisive for the course of my research.

After extensive research I decided to focus on partners, family and friends who carry the big task of taking care of the patient while at the same time coping with feelings that go hand in hand with the acceptation of losing the person they know and love. By far most Alzheimer patients live 506

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City Bus

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1.

Regular city bus Source: unknown

for the Alzheimerbus, but more about the richness of the research which uncovered a lot of the ethical and moral opprobrium attached to the design and healthcare for Alzheimer patients. I believe my creative design process became a clear example of ‘research through design’ which in turn can be used in defense of the need for ‘artistic research’ within discursive practice.

My first idea for the Alzheimerbus was meant as a pick-up service for Alzheimer patients. It allows the informal caretaker some free hours to recuperate.

Interviews I did with informal caretakers and environmental psychologists show that although informal caregivers carry a big burden, they go out of their way to take care of the patient. Therefore it is not my goal to entirely take over the healthcare for example by focusing on institutionalized healthcare, but rather to help them and relieve some of their burden. Additionally the Alzheimerbus gives the patient the possibility to get outside the house where dynamic impulses can

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have a stimulating effect on the mind of the Alzheimer patient. This sensorial stimulation is very important because it enables the patient to feel relaxed which in turn limits the risk of disturbing behavior and feelings of fear and despair.

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2.

Experiments for interior Alzheimerbus, seats turned towards the windows.

Another advantage of using a city bus as a starting point for my design is its approachability. The bus can be a symbol for Alzheimer’s disease in society, create a kind of awareness and get patients and caretakers out of their isolation. Only if we all start caring a little bit more for each other, expanding healthcare costs can be brought to a halt.

I searched for the ultimate ‘bus design’ that could effectuate the above mentioned objectives. I gradually realized that there was not necessarily an ultimate solution and that some of the best solutions could not be achieved only through architectural design.

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3.

Experiments for interior Alzheimerbus, variety of seats in the middle of the bus.

I gained insight in possibilities of positive sensorial stimulation through several haptic experiments in which I tested my different senses consecutively. In addition, the conversations I had with environmental psychologists taught me a lot about balancing sensorial impulses. For instance dynamic views make the patient feel alive and decreases the chance of patients creating their own impulses which can be disturbing. Sounds or movement behind their back and unrecognizable impulses are unwanted.

In my first design experiments I played with the placement of the chairs while taking in account the different stages of Alzheimer’s disease. I considered special cubicles which could be closed off but I also intended to offer a choice between single, double or even group seats. Every seat would have different sensorial and social qualities trough its placement and its size which conveys the message that not every Alzheimer patient is the same.

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4.

Experiments for interior Alzheimerbus, variety of skylights.

Since daylight has a positive effect on the inner clock I experimented with chairs turned towards a ceiling which would contain roof windows. The view from the skylights would be more relaxing than the view from the regular bus windows because of different dynamic sensations.

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Experiments with Commercial Texts

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Experiments with commercial texts on facade of the bus in order to create awareness.

As mentioned, I believe the social perception of Alzheimer’s disease plays a big role for the way we (society and politics altogether) deal with Alzheimer’s in general.

Since the city bus is a typical object in our daily street view, the outside of the bus is often used for commercial interests in order to reach a lot of people. I experimented with some commercial tactics in order to create an awareness concerning Alzheimer’s disease.

Because of the shock effect the images were very effective but unfortunately could also be perceived as a lack of respect towards the Alzheimer patients themselves.

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Carecenter

This triggers an interesting discussion of how we should treat Alzheimer patients. Even within professional healthcare their exist different approaches which contradict each other. On the one hand there is ‘Reality Orientation Training’ (ROT) which is based on the belief that continually and repeatedly telling or showing certain reminders to people with mild to moderate memory loss will result in an increase in interaction with others and improved orientation. In contrast, the idea behind ‘Validation therapy’ is to “validate” or accept the values, beliefs and “Reality” of the dementia person - even if it has no basis in our reality. This put me before an ethical design dilemma: should I base my design on the familiar, which in case of the Alzheimer patients is the recognizable interior of an old city bus, or should I put myself as a designer above this approach and focus on creating an entirely new experience with the risk of upsetting and disorienting the minds of the Alzheimer patients? Do we leave the patient in their own reality or do we constantly remind them of ours?

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6.

Carecenter Hogewey, where 152 demented people live. The nursinghome is a rebuilt of a real living area with streets and shops only then as a secured environment.

Source: http://www. bobadvies.nl/ markten/zorg/ 7.

Busstop inside nursing home.

Source: http://www. refdag.nl/ achtergrond/ onderwijssamenleving/ beleefwereld_ verpleeghuis_ stellinghaven_slaat_ aan_bij_dementerenden_1_697048

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8.

Alzheimerbus #1 Interior based on an old tram.

In my preliminary design I ruled myself out as a designer and put the patient first by copying the recognizable atmosphere of an old tram. The wood gives off a warm tactile impulse in contrast to modern materials like steel or glass. windows with adjustable transparency

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Inspiriation for bus interior, Old tram in Lisbon

adjustable chairs with headphones and massage function

room for one or two wheelchairs

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entrance

coffee and sandwich bar

seats for caregivers

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10.

Experiment with sitting cubicles hanging from the ceiling.

My next step was to achieve a more bold design for which I attempted to focus on creating a new experience instead of focusing on the regular bus experience.

I started experimenting with the sensorial sensation of the design by for instance releasing the chairs from the moving bus floor by hanging them from the ceiling. Every seat would get a private skylight and again there would be a choice between private or double seats. In addition the caretakers role was taken in consideration by providing a walking path around the seats which would make it easy to guide the patients to the chairs.

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11.

Experiments with seats placed diagonal to the window for optimal viewing.

Seats can be hung from the ceiling or placed on the busfloor.

The biggest disadvantage of this design was the distance between the chairs and the windows.

Although all of the senses are very important, the dynamic view from the bus overrules the other senses which is why I gave it some more attention in my design.

I found that the best way to experience the view is actually sitting diagonal to the windows; in this way the eyes can participate better on the moving landscape. A second step would be to also make the windows diagonal so they would be parallel to the seats.

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12.

Experiments with bus facade

This again raises the ethical question of reality orientation. In how far should the bus be recognizable as a bus? By altering the faรงade of the citybus, I was altering the whole outside appearance of the citybus.

I started testing the boundaries of the city bus: How far could I go for it to still be recognizable as a city bus?

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13.

Grotto interior experiments

I also took this ‘reality experiment’ to the interior design of the bus by experimenting with positive and negative space, creating a grotto kind of structure.

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14.

Tribune bus

At one point of conceptual despair I may say, I even left behind the whole contours of the bus, creating a whole new vehicle, as a kind of building on wheels, which would contain a tribune. The tribune would serve as a stage on which the patients would literally be displayed to the outside world.

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Luxury camper Source: http://luxatic.com/ amazing-luxury-campervan-by-marchi-mobile/ marchi-mobile-luxurycamper-van-4/

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Experiments with private sitting cubicles.

Every seat has its own sensory qualitys.

A whole new bus experience.

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17.

Experiments with making a clear distinction between Alzheimer patients and the regular passengers.

The Alzheimer patients would have nice private sitting cabines with a skylight and seats turned towards the windows. The seats for the regular buspassenger becomes a kind of supplement of the Alzheimer cubicle.’ These seats are turned inwards.

Throug viewing holes a tension is created between the Alzheimer patient and the buspassenger inspired by the converstaion seat.

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18.

Victorian conversation seat.

Source: http://www. suttonantieks.co.uk/ antiquefurniture/ antique/ victoriansofa-conversation-seat/

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19.

Experimenting with placement of ´Alzheimer seats´ in between regular bus seats.

Realizing that I had departed from my original concept too much I reflected back on my choice for a city bus: the sensorial impulses and bringing Alzheimer patients in society. I started experimenting with bus designs that tested the hierarchy between Alzheimer en non-Alzheimer patients which brought me back to the stereotypical city bus. I realized that making a special ‘Alzheimerbus’ has a certain alienating effect and would only further widen the gap between Alzheimer’s and society. This was the moment when I first decided to get rid of the ‘Alzheimerbus’ and focus on the placement of ‘adjusted’ seats for Alzheimer patients inside regular city buses. I changed the name from ‘Alzheimerbus’ to ‘Lijn#3210’ in order for it to be less confronting. The pick-up service had changed into an integration of the Alzheimer patient into the existing bus system. By the way the seats are placed, the regular bus patient would be provoked to make contact with the Alzheimer patient, or the other way round.

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20.

Special seats in the city bus for people with disabilities.

But the ‘adjusted’ or rather ‘special’ seats still expressed the same problem as the ‘Alzheimerbus’ only then on another scale. It also occurred to me that city buses already contain ‘special seats’ for disabled people and/or people with wheelchairs. How do they experience this special treatment?

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From Alzheimerbus to Lijn#3210

Eventually I concluded that it was not so important to design something especially for Alzheimer patients, but that it was more about making a political and moral statement towards society. Surely interior design could do a lot of good for the environmental experience of the Alzheimer patients, but because of the path I chose it became more important for me to make people think and act differently towards Alzheimer’s in general.

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Conclusion

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From Alzheimerbus to Lijn#3210

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Photoreport ‘Theo en zijn stoel’

By Martijn Evertse and Naomi Cheung San

Therefore, my last approach cannot really be called a design. Lijn#3210 consists of the favorite chairs of the Alzheimer patients, or rather the people suffering from Alzheimer’s disease, which are placed inside existing city buses in between the regular bus seats. The chairs are symbolic for Alzheimer’s disease but especially for the person behind the disease. The chairs are turned towards the windows for optimal experience and would be accessible for as well Alzheimer patients and regular bus passengers.

Hopefully it expresses that experiencing the world in a different way is not necessarily a bad or a scary thing. Besides a transportation device, the bus now becomes a place of reflection, encounter and new experiences.

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Photoreport

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Special Thanks

Credits

All Students

Special Thanks to

Credits

All Students

Special Thanks to Margaret Tali Thesis tutor of all students Ira Koers Turor of Tom, Ricky and Naomi Allard van Hoorn Tutor of Jack Femke Bijlsma Tutor of Wenqian Paul Toornend Tutor of Chanida Marieke Sonneveld Examinator Graduation on 11th of July Marieke van Rooy Examinator Graduation on 29th of August Jurgen Bey Director Sandberg Instituut Diederik Klomberg Artist, Guest lecturer at Graduation Show

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Ianus Keller Researcher, Guest lecturer at Graduation Show Lino Hellings Artist, Guest lecturer at Graduation Show Sarah van Sonsbeeck Artist, Guest lecturer at Graduation Show Marjo van Baar Staff Coordinator Sandberg Insituut Nancy van Vooren Office Manager Sandberg Insituut ARCAM for the graduation exhibition especially thanks to Marc Peperkamp, Astrid Toorop

Colophon

Master of Interior Architecture Sandberg Instituut

Insight Series #3 Urgent Matters – Through Space

Colophon

Insight Series #3 Urgent Matters – Through Space © Sandberg Instituut Amsterdam, 2012 Fred. Roeskestraat 98 1076 ED Amsterdam The Netherlands T +31 (0)20-588 2400 www.sandberg.nl www.sandberg.nl/interior/ Head Master Interior Architecture: Henri Snel Coordinator Master Interior Architecture: Rinske Wessels Students: Tom van Alst Ricky van Broekhoven Jack S.C. Chen Wenqian Luo Chanida Lumthaweepaisal Naomi Cheung San Concept & Design: Anja Groten Printing and binding: Edition Winterwork Edition: 100 copies

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Insight Series #3 Urgent Matters – Through Space

Tom Images p.9 Charles (patient) and Jane (caretaker), November 2006, Texas.

Source: Google image 2.

Margaret Nance, December 31 2010, New York.

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environment and social behavior Monterey, California: Brooks/ Cole publishing company Farman, J. (2012) Mobile Interface Theory (Embodied Space and Locative Media) New York and London: Routledge Hall, E.T. (1966) The hidden dimension New York: Anchorbooks Orwell, G. (2009) Nineteen eightyfour. 6th edition. London: Penguin Books p.8 Websites Teeffelen, K. (2012) U bent geen klant maar een product.

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Road to Heaven: Encounters with Chinese Hermits, Mercury House, May 1, 2009 Brigitte Kölle, ‘The Challenge’, Weisse Folter: Gregor Schneider, Verlag der Buchhandlung Wal- ther König ,2007 Courtesy Elmgreen& Dragset , Try again fail again fail better. Frame#57 JUL/ AUG 2007 Duncan Mclaren, In RuinsThe once great houses of Ireland, Bulfinch Press - Little, Brown & Company, the USA, April 1997

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Master of Interior Architecture Sandberg Instituut

furl=http:// calitreview. com/wpcontent/ http://blog. warmenhovenvenderbos. com/2010/02/ 15/fredericgeurtsarchitectural -monumentaldialogue-and -balance/ http://www. dominadesign. com/EN/Alessi -korbschale,fruit-bowl, -centrepiece, -citrusbasket,-tea light-holder -la-stanzadello-scirocco-di-MarioTrimarchi1761P.aspx http:// surface research-hj. blogspot. http://surface research-hj. blogspot. http://www. frieze.com/ issue/review/ gregor_ schneider/

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Image United’haitation de Marseille, Le Corbusier, 1947-1952 Maldonado, The Idea of Comfort, 1991, p. 35 Kenyon, 1999, p. 86, 89, “A Home from Home” (1999) Brookner, 1984, p. 172, Hotel du Lac (1984) Reflections, Benjamin, 1978, p. 155 The Meaning of Things: Domestic symbols and the self (2002) Csikszentmihalyi and RochbergHalton, 2002, p. 17 Csikszentmihalyi and RochbergHalton, 2002, p. 59 The System of Objects (2005), Baudrillard, p. 13, 15-16

Alain de Botton, The Architecture of Happiness, The Secret Art of Furnishing your Life, London: Penguin Books, 2007.

Annemarie Mol, The Body Multiple: Ontology in Medical Practice, Durham and London: Duke University Press, 2002.

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Insight Series #3 Urgent Matters – Through Space

Haven and London: Yale University Press, 1975.

Dalibor Vesely, Architecture in the age of the Divided Representation, The Question of Creativity in the Shadow of Production, London: The Mit Press, 2004.

Margo Trappenburg, Genoeg is genoeg, Over Gezondheidszorg en Politiek, Amsterdam: University Press, 2008.

Michel Foucault, The Birth of the Clinic: An Archeology of Medical Perception. New York: Vintage, 1973.

Gert Olthuis and Carlo Leget, Menslievende Zorg in de Praktijk, Berichten uit het St. Elisabeth Ziekenhuis, Den Haag: Boom Lemma, 2012.

Michael Bury, Health and Illness, Cambridge: Polity Press, 2005.

Noor Mens and Annet Tijhuis, De Architectuur van het Ziekenhuis. Transformaties in de naoorlogse ziekenhuisbouw in Nederland, Rotterdam: NAi Publishers, 1999.

Juhani Pallasmaa, The Eyes of the Skin: Architecture and the Senses, Chichester: Academy Press, 2005.

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heidszorg in Nederland, Rotterdam: NAi Publishers, 2010.

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Anders bouwen voor betere zorg, Bussum: Thoth, 2009.

Ziekenhuis als Leefomgeving, Sdu Uitgevers, jaargang 42, 2011, p. 39.

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Een Verkenning van de Mogelijkheden, Utrecht: Centrum voor Criminaliteitspreventie en Veiligheid, Hogeschool INHolland and the Police Academy, 2010.

Karen Heijne, ‘Zorgboulevards. EGM Architecten’, Architectenweb Magazine, 45, 2011, p.

54-59.

Marit Overbeek, De Architect, Interieur,

Roger Ulrich and others, A Review of the Research Literature on EvidenceBased Healthcare Design, Georgia: Institute of Technology, 2008.

Articles

Master of Interior Architecture Sandberg Instituut

Roger Ulrich, ‘View through a Window May Influence Recovery from Surgery’, Science, 1984.

Websites www.healthdesign.org www.planetree.nl http://www. biomedcentral. com/14712415/7/14 www. liefziekenhuis.nl http://programma.vpro. nl/deslagomnederland/ meldingen/ lelijksteplekvannederland-speellijst.html http://www. healthcaredesignmagazine.com/ article/conversationroger-ulrich? page=2&com_ silverpop_iMA

Insight Series #3 Urgent Matters – Through Space

_page_visit_ %2Farticle%2F conversationroger-ulrich=1 http://www. martinizieken huis.nl/OverMartini/Zorg visie-MartiniZiekenhuis/ HealingEnvironment/ http://www. architecten web.nl/aweb/ projects/ project.asp?

PID=20606 Promotion clip or minidocumentary: OMP Sittard hospital of the future bonnema architecten the Netherlands.wmv http:// www.youtube. com/watch?v= -96GhXrAnzc http://www. zorgcentraonline.nl/ actueel/ Zorgcentra_ ziekenhuis_ van_de_21e_ eeuw.html

Lecture by Bas Römgens of VenhoevenCS about the Core Hospital during the lecture series ‘Reset the City’ in s’Hertogen bosch 2012 Images p383 6.

Carecenter Hogewey, where 152 demented people live. The nursinghome is a rebuilt of a real living area with streets and shops only then as a secured environment.

Source: http://www. bobadvies.nl/ markten/zorg/ 7.

Busstop inside nursing home.

Source: http://www. refdag.nl/ achtergrond/ onderwijssamenleving/ beleefwereld_

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Master of Interior Architecture Sandberg Instituut

verpleeghuis_ stellinghaven_slaat_aan_ bij_dementerenden_1_697048 p 395 14.

Tribune bus 15.

Luxury camper Source: http://luxatic.com/ amazing-luxurycamper-van-bymarchi-mobile/ marchi-mobileluxury-campervan-4/ p 399 18.

Victorian conversation seat.

Source: http://www. suttonantieks. co.uk/antiquefurniture/ antique/ victorian-sofaconversationseat/ p 407 21.

Photoreport ‘Hans en zijn stoel’

By Martijn Evertse and Naomi Cheung San

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