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SENSORY STIMULATION IN PEDIATRIC HOSPICE

Kelly Pyle “The best way to acquaint oneself with architecture is not to read about it: it is to look, touch, smell, and listen to it - a building only gains meaning when it becomes part of human life” - Alvar Aalto (Barham) Architecture is an extension of nature into the man-made realm; the way in which architects design impacts our understanding and experience of the world. “It directs our attention and existential experience to wider horizons” (Pallasmaa 41). Therefore, it is the responsibility of architects to design an architecture of the senses, an architecture our bodies can explore and relate itself to within the greater expanses of space. An architecture of the senses, engaging with the body and stimulating the mind, is fundamental to a holistic healing environment. When a child has terminal illness, when the body begins to shut down at the end of life, communicating with the outside world through means of speech and action can be painful and unmanageable. Feeling the warmth of the sun or hearing the chirping of birds is our innate connection to nature and the world; this primordial communication with the body comforts and heals. The

therapeutic powers of nature are experienced through the senses. Depriving the body of sensory connection means removing the body from its surroundings. Much of modern architecture ignores the body, creating cold, distant, and unappealing space. Architecture must act as the mediating communication between body and world, engaging in the essence of what it is to be human in order to have a rich life until death. The Pediatric Hospice Setting When discussing a pediatric healing environment, sensory stimulation is critical. More so than adults, children instinctively explore and understand the world through the senses (Day and Midbjer 85). Pediatric hospice patients range in age from infant to young adult. While adults may only receive hospice care with a diagnosis of less than six months to live, pediatric hospice cares for any child who has been diagnosed with life-limiting conditions (Friebert et al.). This allows for a much longer length of care, providing support to the family from chronic diagnosis, to end of life care, and through bereavement. Children cared for by pediatric hospice include all levels of mobility.

2 41% of pediatric patients have a genetic or congenital diagnosis, 39% have a neuromuscular diagnosis, and 19.8% have a malignancy diagnosis (Friebert et al.). With such a wide range in age and illness, creating a space that comforts and heals is possible through sensory stimulation. Sensory elements are the communication device between world and child. If the child is active and mobile they may freely explore the space, and when a child’s exploration is confined to bed, the sensory elements come to them, always as a way to communicate and understand the surroundings.

questions: How can architecture create healing, interactive, and stimulating sensory experiences? How does sensory stimulation contribute to the creation of a healing place?

The senses act as a form of nourishment to the developing brain of a child, according to Dr. Jeff Green . Humans are stimulusseeking beings, noticing stimulus is innately key to survival. The survival is much simpler in the modern world; we don’t function at our best without sensory stimulation. In an environment void of sensory stimulation, the brain can’t find ways to stay occupied; the brain As Wilbert M. Gesler describes, the deteriorates and goes to sleep, word heal derives from Old English nothing else to stay engaged haelon, meaning wholeness. and awake (Day and Midbjer 83). Healing cannot exist without “Sensory deprivation experiments the integration of the patient’s have shown that if all the senses are physical, mental, spiritual, and denied stimulus, within seconds a social components. The connection risk to life develops” (Day 203). A between mind and body is sensory lacking environment is in no inseparable, each affecting the other way the proper healing environment, (Gesler 3). As discussed before, yet it is sadly what we have come to this connection occurs through the expect out of the common hospital senses. setting. Sensory nourishment is cast aside, medical intervention is This paper attempts to investigate the only relevant “healer”. In the the importance of sensory extreme case, all natural sensory stimulation in the pediatric hospice stimuli are cut off and replaced setting, and answer the following with the mechanics of a hospital; Sensory Stimulation in Pediatric Hospice

Textures Invite Touch Materials throughout the hospice bring warmth and invite touch and interaction; wood, stone, and fabric make up the surfaces.

flickering fluorescent lighting, frightening beeping sounds, cold tile floors, all uncomfortable and unapproachable elements because they are innately unnatural to the human body. Traditionally, we know the senses as sight, smell, sound, touch, and taste. The psychologist, J.J. Gibson has categorized these five sensory systems: the visual system, the auditory system, the haptic system, the taste-smell system, and the basic-orienting system (Gibson 44). The following text breaks down each sense, its environmental impacts on the human psyche, and its importance in a healing environment. The Haptic System The body acts as the mind’s “locus of perception” (Pallasmaa 10), the skin being the first medium of communication. Pallasmaa believes all sensory experiences are modes of touch, acting as the parent of our eyes, ears, nose, and mouth. The skin has impeccable accuracy in feeling texture, weight, density, and temperature of anything it comes in contact with; feeling the tactile and sensory differences in nature is an incredibly healing experience (Pallasmaa 59).

4 Play of Light and Shadow Kinetic wooden louvers line the courtyard, allowing winds from the bay to manipulate the facade, providing a constant flutter in the breeze.

The tradition of architecture is rooted in hapticity. Indigenous architecture of clay and mud is made by the hand and communicates a human connection. Natural materials create a patina of wear, an aging that satisfies the mental need to grasp that we are rooted in the continuum of time. (Pallasmaa 31). Much of modern architecture ignores the tactile benefits of natural materials, preferring steel, glass, and concrete. These manufactured materials are cold, dull to touch, and sterile (Day and Midbjer 86). Natural materials such as wood, brick, and stone express age and history, contain human warmth and invite touch (Holl 29). Texture makes all the difference in an approachable and unapproachable space; “The harder and more lifeless our surroundings are, the more tired, tense, and sapped of life we tend to become. The softer and more alive they are the more renewed, relaxed, and healed we tend to be” (Day 52). Children innately learn and explore through their hands; therefore children understand the world through touch (Day and Midbjer 85). Careful selection of materiality and texture in a pediatric environment

5 are critical. The architecture must provide tactile exploration of natural materials and soft textures. Touch is the most critical sense for young children and those with special needs. Walls and floors should invite touch with soft and stimulating textures. Wood is friendlier than metal; textured walls better than smooth; soft floors more than hard (Day 20). Architecture creates encounters and confrontations that interact with body and memory, directing movement and behavior. Architecture must be considered as a verb, not a noun. The exterior of a building creates an approach, not just a visually appealing facade, and a fireplace acts as a sphere of warmth, not just a flickering light. The Visual System “In great spaces of architecture, there is a constant, deep breathing of shadow and light; shadow inhales, and illumination exhales, light.” (Pallasmaa 47). Deep shadows are essential to imaginative and creative thought. Deep shadows give way to unfocused, meditative thinking. In modern architecture, the window has become merely an absence

of wall; it has become about quantitative light, not qualitative. This quantitative light loses its atmosphere and intimacy, exposing us to a constantly public life. “An efficient method of mental torture is the use of a constantly high level of illumination that leaves no space for mental withdrawal or privacy; even the dark interiority of self is exposed and violated.” (Pallasmaa 49). An architecture serving our innate desire for intimacy plays with light and shadow; introducing darkness and shadows give the feeling of shelter and protection. On the other hand an architecture creating public, communal space is more exposed to the open natural light of the outdoors. Color is an important aspect of light. Every color transmits a specific physical wave our eye records as color stimulus. Each color carries unconscious associations and symbolism. Red is associated with blood and fire, and is widely accepted in the scientific world to speed up the heart and raise blood pressure. Blue is closely associated to the sky and sea, and is known to lower blood pressure and calm the nerves. Green is associated with nature, bringing a mindset

6 of life and rejuvenation. Yellow is associated with the sun, energizing and activating the mind (Meerwein et al. 4). Colored light has a different effect from pigment - with light you can feel raised up in a mood, but with pigment pressed down into it. Translucent colored veils produce a similar effect of colored light. “Light shining through foliage can be both life-filled and peace-bringing” (Day 48). Studies investigating the impact of sunlight on hospital patients showed positive effects. Beauchemin and Hays found that patients had shorter length of stay with access to sunlight, and used 22% less pain medication. Benedetti et al. discovered that bipolar depression patients with rooms with access to morning light have shorter length of stays than those with evening light (Dijkstra et al. 173). Beyond sunlight, Roger Ulrich studied certain views and their impact on patients. Patients with a view to nature had shorter stays, reported better moods, had less complications, and took fewer medications (Dijkstra et al. 175). Based on these studies, it is safe Sensory Stimulation in Pediatric Hospice

to assume that what we see has a large impact on the human psyche. Our primordial tendencies are clearly still important; we feel most comfortable in the shelter of shadows, with views to nature and sunrise. These visuals are critical in creating architecture that heals. The Auditory System “Anyone who has become entranced by the sound of dripping water in the darkness of a ruin can attest to the extraordinary capacity of the ear to carve a volume into the void of darkness. The space traced by the ear in the darkness becomes a cavity sculpted directly in the interior of the mind” (Pallasmaa 50). We have an amazing ability to experience space through sound; hearing shapes and materials articulates our understanding of a place.

Wind Becomes Music Exterior columns act as wind flutes. Breezes play through the steel column, providing soft natural music. Manipulating segments of the column produces unique sound.

Fabric and other soft material are also acoustically inviting. One can immediately recall the acoustic harshness of an empty house, as opposed to the soft, intimate sounds of a furnished, lived-in home. Wood as an interior finish with elements of fabric create pleasing acoustic qualities within a space.

Studies were conducted on the effect of certain acoustics on the recovery of hospital patients. Hagerman et al focused on preventing negative acoustics. In rooms without acoustic absorbing material, rehospitalization was significantly higher, as was the need for more medication. Williamson (1992) studied sound as positive distractors in hospital patients. Patients who listened to sounds of the ocean as they slept scored significantly higher on quality of sleep (Dijkstra et al. 175). Diette et Modern materials have a tendency al. (2003) found similar results when to sound cold and harsh, while he studied the impact of nature natural materials and fabrics provide sounds on patients undergoing soft, intimate sounds. It is no flexible bronchoscopy; those hearing surprise that humans find natural sounds of nature needed less pain materials more acoustically pleasing medication (Dijkstra et al. 177) than manufactured. Wood has an ability to reflect sound pleasingly; Its Experiencing space through the beautiful, unique acoustic qualities ear has the power to comfort or are the reason wood is used for agitate. Designing an acoustically many musical instruments (Lachot). healing environment requires careful

8 Aromatherapy Therapeutic fragrances such as lavender and eucalyptus flow through the courtyards and interior spaces.

9 consideration of material, reduction of noise, and emphasis on the sounds of nature. The Taste-Smell System Our strongest connection to memory is experienced through smell. “A particular smell makes us unknowingly re-enter a space completely forgotten by the retinal memory; the nostrils awaken a forgotten image, and we are enticed to enter a vivid daydream” (Pallasmaa 54). The olfactory system has more receptors than any other sense; we can detect more than 10,000 unique odors (Pallasmaa 54). Although easily overlooked, the olfactory system explores a space in a unique way, understanding the surroundings through memory. Olfactory-evoked memories have been studied in relation to verbal and visual memory. Most memories evoked by smell bring us back to a moment in childhood, while verbal and visual cues lead to memories from adulthood (Willander and Larsson 242). Therefore, it is evident that smells are an important part of a child’s experience of the world. Lehrner et al. (2000) studied the

effects of ambient odor on patients in a waiting room. Women exposed to orange essential oil reported less anxiety, improved mood, and increased calmness (Dijkstra et al. 175). Studies on the effect of fresh air found that students with access to natural ventilation and open windows performed 7-8% better on tests (Schweitzer 74). The Basic Orienting System Architecture has to respond to the body’s archaic tradition; it must communicate to our primordial tendencies: our needs of comfort, protection, and home (Pallasmaa 60). Sizing up a new space, we unconsciously mimic its structure, we feel its gravity and connection to the earth. Once the body understands its place in space, we feel pleasure and protection (Pallasmaa 67) Going to a new strange place, especially a hospice, would be a scary experience for a child. The architecture must create a strong sense of protection and safety. The secure physical base is important for feeling safety. Heavyweight, solid space with private niches, nooks, and hideaways communicate safety to the body. “The chief benefit of the

house [is that] the house shelters daydreaming, the house protects the dreamer, the house allows one to dream in peace” - (Bachelard et al. 44) Heavy materials communicate this comforting sense of safety. While children need a place to retreat and return home to, they also need space of freedom and community. Beyond the secure, enclosed space is the in-between realm, where spontaneous play occurs. Just as a picnic occurs near rocks instead of on the open beach, children need the security of protective edges. Children want to be near houses, trees, etc. “This edge-realm weaves between security and stimulation, the safe and the stretching”. This setting offers the richest and most varied activity opportunities (Day and Midbjer 27). Kids find themselves most comfortable playing in this “in between” wilderness and home (Day and Midbjer 27). The retreating home base and the exploratory edge realm can be felt through the weight and gravity of the space. The body’s muscle and bone unconsciously connects and understands the weight’s protection.

11 Warmth of the Fire A central campfire brings hospice communities together. The smells, sounds, sights, and warmth emanate and entice.

10 The Sensory Immersion of Camp A walk through the forest is healing because it is a holistic sensory experience (Pallasmaa 41). You see the shadows of leaves playing on the forest floor; you feel the breeze and warmth of the sun as you walk in and out of the clearings; you smell the fresh wood and decaying bark; you taste the crisp leaves in the breeze; you hear the crackling of branches and the chirping of birds. This total immersion in nature is experienced by every sense, rooting you in the place and time. Your sense of reality is strengthened and articulated by the experience. This is holistic healing. Architecture must strive for this holistic sensory connection. A fine architectural experience evokes all senses, and brings an intimate contact to the body. When the senses work together, and not in isolation, they begin to evoke an essence of the place. “The senses - all together - give a picture of a reality which is not adequately described by any one sense, a reality which we call spirit, the spirit of a person, event or place” This spirit affects us deeply (Day 20). Through the sensory experiences discussed and their effect on the Sensory Stimulation in Pediatric Hospice

human psyche, it is clear that humans innately relate back to our ancient connection to nature. We are instinctively drawn towards natural sensory experiences, and environments once important to survival now unconsciously comfort and heal the modern soul. We can look back on mankind’s origins and primitive architecture as inspiration for creating a healing environment.

of more American children than any other tradition besides school (Garst). The camp movement began in the 1880s as part of the back-tonature trend accompanied by urban parks, national parks, and resorts. The aim was to give urbanity authentic respite of country life. This trend has remained a staple of the American childhood. Each year, more than 11,000 children and adults experience camp in America Throughout the history of mankind, (Van Slyck). Camp provides children architecture has existed first and with a fully immersive experience foremost as shelter, a sanctuary within nature, of exploration and for mankind to retreat from the adventure. This immersion in nature wilderness. From this origin of is total engagement with natural architecture comes the tent. The sensory stimulation. Children feel tent provides a connection to nature the healing benefits of an holistic that most modern buildings have sensory experience at camp. lost. The boundary between indoor Sheltered at night by tent or cabin, and out is unclear with a tent; nature and exploring the open surroundings seeps in every side. Nomads view by day, all of the senses together their tent as shelter, sanctuary, and explore the natural surroundings. temple, a holy place, a “sacred universe”(Faegre 93). This opportunity to reconnect with nature in a close-knit social support As architecture has innovated over group should be available to all time, there has been a tendency children, regardless of illness or to disconnect from the outside disability. The healing effects of world altogether. In our modern camp allow terminally ill children and age, reconnecting with our roots in youth to be free from the worries nature comes through the camping of their condition, and just be a kid experience. Camp is the beloved again. A playful, social, and natural social institution that reconnects us healing environment is cultivated in with nature and touches the lives a camp setting.

12 Mills Camp Meditation The hospice is comprised of a series of private spaces reaching up to the sacred sky. The edge realm between these spaces are courtyards and community living and play.

Mills Camp, a Pediatric Hospice The ideas of sensory stimulation within a camp setting aim to provide a comforting, stimulating, and healing place for pediatric hospice. Within the eucalyptus forest and along Seminary Creek, the Mills College site in Oakland, CA is an ideal location for a healing experience in nature.

Conclusion Bringing the sensory elements of nature into the realm of the hospice provides a holistic healing experience. The healing aspects of the place can be explained through Wilbert Gesler’s elements. The built environment provides a protected experience of the natural environment. Nature While patient rooms act as home communicates with the architecture, The hospice is organized as clusters base for each patient, the spaces and both communicate to the user. of enclosed “home bases” or cabins, in-between these shelters are the Symbolically, the idea of camp arranged within the open space. edge-realm mentioned previously. promotes childhood exploration and The entire facility is protected by a Natural light pours into this open adventure, and sensory elements wooden canopy roof. This structure space; creating community and throughout the building come with undulates up and down; these activity. While outside their individual meaning. Water, fire, light from undulation hint at the dramatic light “home base”, patients feel sheltered above, and colors all unconsciously wells hurtling up within enclosed by the edge realm, yet are still part hold symbolism, and are used shelter spaces. Under these of the open. to create certain atmospheres prominent roofs is where guests throughout the building. spend most of their time in the The hospice acts as an architectural facility, in the comfort of privacy and extension of nature, immersing Architecture must engage the shelter. Its materiality and gravity users in sensory stimulation of the senses in order to create this promotes a sense of security; natural environment, in a protective healing place. Engaging the body this security opens up to the sky, and sheltering setting. The and stimulating the mind, holistic promoting freedom not confinement. architecture incorporates elements sensory experiences ground you in throughout the building that play the moment and place to heal. The enclosed spaces, therapy and with the sensory attributes of “Once the body understands its resident rooms, act as tent and nature, inviting exploration. Spaces place in space, we feel pleasure and sanctuary within the facility. As a constantly breathe with the natural protection” (Pallasmaa 67). place of retreat and shelter within variations throughout the day and Sensory elements aid children nature, these sanctuaries provide season, creating sensory variety to with terminal illnesses to fully filtered lighting, views, sounds, interact with the user. explore and understand the world smells, breezes. The space’s light around them, providing for them to scoop bringing light in from the experience life to its fullest. sky represent the eye of heaven in nomadic cultures. Therapy spaces filter in colored light from above. Each space has a unique color for its unique atmosphere and purpose. For instance, the art room is bathed in an energizing yellow light, while the library receives a calming blue light.

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Sensory Stimulation in Pediatric Hospice

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Photo Credits 1. Romero, Ricky. Flickr. 2. Suspense. INVIVIA Gallery, Cambridge. 3. Pyle, Kelly. Textures Invite Touch. 2016. 4. Pyle, Kelly. Play of Light and Shadow. 2016. 5. 2014. Deceptively Simple. 6. Yates, Adam. Water Drops into a Cave Pool. Oregon Caves National Monument. 7. Pyle, Kelly. Wind Becomes Music. 2016. 8. Pyle, Kelly. Aromatherapy. 2016. 9. Warmerdam, Alexis. 10. Canales, Ben. Group Fire. 2010. The Star Trail. 11. Pyle, Kelly. Warmth of the Fire. 2016. 12. Pyle, Kelly. Mills Camp Meditation. 2016. 13. Pyle, Kelly. Meditation Room. 2016.

Sensory Stimulation in Pediatric Hospice