Z0D21

Reclaiming The Asylum

by Felix White

Reclaiming The Asylum How can the architecture of the Victorian asylum be used in modern day dementia treatment?

Felix White Student No. 160314090

Contents

1-10

Chapter 1

Introduction

Chapter 2

NHS Modular Ward

11-26

Chapter 3

Drivers of Change

27-34

Chapter 4

Moral Architecture' at the York Retreat

35-48

Chapter 5

Moral Architecture' Today, Maggie's Centres

49-62

Chapter 6

Conclusion

63-68

List of Illustrations

69-70

Bibliography

71-76

Fig. 1

1

Introduction Chapter 1

2

Introduction

Dementia is an undeniably pervasive issue in the UK today, with roughly 850,000 people living with the illness, and this figure forecast to rise to 1.6 million people by 2040 (Alzheimer’s Society, 2019). With no cure currently available, merely medication to reduce the behavioural effects, the provision of care for dementia sufferers is of the upmost importance (NHS, 2018). The architecture of dementia wards in particular can be used to create a healing environment. If done correctly and effectively, the design of wards has the possibility to not only improve quality of life for patients, but also contribute to the management of the effects of dementia.

In this dissertation, I will be considering how a dementia ward might benefit from a consideration of the architecture of the Victorian asylum, founded in 1796, namely the ‘moral architecture’ of The York Retreat. What initially drew me to look into the subject was the representation of the Victorian asylum as so intensely horrific in modern popular culture, largely based on the reputation of asylums such as Bethlem. Stories told of widespread neglect and appalling conditions, which patients would have to endure for years at a time. Limited respect for those that would then have been called ‘mad’ or ‘lunatics’, and thus housed in such ‘lunatic asylums’ with these conditions, meant little care was put into their environments. Asylums were rarely purpose built, but rather converted in order to house the ‘insane’. Many of these conversions

3

Introduction

are now considered to have been no better than stables. If one were to transpose these conditions onto modern times, they would be utterly unacceptable, with public outcry and contemporary regulations guaranteeing immediate closure of such institutions. In early Victorian England, this was normalised to the extent that the public were able to pay to visit Bethlem, and its importance as a tourist attraction was considered to be equal to that of The Tower of London or Buckingham Palace (Jay, 2016, p.47). This attitude translated directly into the architecture of these establishments, with much of a patient’s surroundings likely to have hindered rather than helped their conditions. Furthermore, there was limited medical and psychological understanding of the causes of such conditions. Though many of the Victorian asylums therefore were cruel places of neglect and mistreatment, as is popularly thought, the emergence of progressive asylums, those that we might learn from today, is often overlooked.

A more humane form of treatment was developed towards the end of the 18th Century, called moral therapy, which in turn became more popularised during the Victorian era and was interpreted into the architecture of the buildings it was practiced in (Edginton, 2003, p.106). As attitudes began to change, so too did treatments, as greater resources went towards medical research into the subject.

While asylums such as Bethlem still existed in the Victorian era,

4

Introduction

thus allowing the stereotype of the horror of such institutions to endure, moral treatment asylums began to open their doors. These progressive Victorian asylums modelled themselves on The York Retreat, and while undeniably less developed than what we would now call a modern dementia ward, many of the values present in the design of these healing environments could be transposed onto a modern hospital and add value to the treatment of dementia patients.

Asylums in which the ideals of Moral Therapy were implemented dispute the blanket statement, which has entered into widespread public opinion, that all Victorian Asylums were cruel institutions built to confine patients in the same way prisons were built to detain (Edginton, 1997, p.91). Rather, in many ways these asylums could serve as examples on how to create a healing environment.

The York Retreat was the asylum at the frontier of this new type of treatment, wherein the design of the asylum and environment created both within its walls and through its surrounding natural environment contributed significantly to the healing process. This was entirely unlike other asylums of the time, which participated in such somatic remedies as seasonal bleeding, cold showers, purging, or blistering (Jay, 2016, p.47). Rather, moral therapy was strongly opposed to the use of the medical practices of the time, preferring to use interaction and the implementation of a

5

Introduction

strict routine in tandem with architectural design in order to heal.

Reflecting on the successes of these aspects of the York Retreat, in particular the details of its design, might therefore indicate where the implementation of its practices might aid in the treatment of dementia.

When looking for inspiration on how to improve dementia ward design, I wanted to investigate how a more specialised, purposebuilt example of medical architecture might have successfully brought similar ideals to The York Retreat into modern times.

Through this research, I came across Maggie’s Centres, a non-profit organisation which constructs small domestic refuges for cancer patients across the UK and abroad. They aim to provide a refuge away from the institutional and sterile hospitals in which patients largely receive their treatment. The charity currently has 19 refuges, which would likely be called asylums had the word not fallen out of modern-day usage due to its tarnishing by the poor asylums of the 19th Century. Though intended for cancer patients, many ideals and aspects of the brief, created by founders Maggie and Charles Jencks, are similar to those that might be required in the design of a dementia ward. Rather than concentrating on healing the cancer of the patients at each centre, the focus is on providing comfort and stability in reference to their mental health, which is known to suffer greatly while enduring serious, long-term conditions such

6

Introduction

as cancer. The aspect of the refuges of bringing patients together, under one roof, contributes to their mental health healing in itself, through enabling patients to realise they are not alone, and provides a sense of comradery. The design philosophy used by these Maggie Centres may also provide us insight into the use of architecture in modern day dementia wards.

Indeed, many similarities can be drawn from the Moral Therapy of the 19th Century and the particular therapy provided by Maggie Centres, providing us with an example of how these Victorian techniques can be adapted to modern day medical care. For example, there is no provision of physical-medical treatment.

Instead, both institutions attempt to help their patients through the environment created internally and externally through design, interactions between patients and carers, and the creation of a routine through various activities. Looking in more detail at the design aspect of the treatment, both are attempting to create a domestic environment through their architecture. William Tuke, when founding the York Retreat, aimed for the design to resemble a typical Georgian home of the time (Edginton, 1997, p.94).

Similarly, the Maggie Centres achieve a domestic atmosphere by making the kitchen, specifically the kitchen table, the focal point of each centre, just as many contemporary family homes aim to do (Maggie’s Centres, 2020).

7

Introduction

After the deinstitutionalisation of the asylums, they were replaced by our contemporary NHS dementia wards (Leff and Warner, 2006, p.68). NHS architects chose a modular design, motivated by low cost, with the belief that every NHS service would be able to use the modular unit, from maternity to geriatrics (Leff and Warner, 2006, p.68). This fails to take into consideration, however, the intricacies of personalised care often required by dementia patients in comparison to others. In most other NHS care sectors, care is administered at the bedside. In dementia care, however, the healing process occurs when socialising in communal areas or partaking in activities, for example in the fresh air. The bed is a place to sleep rather than the epicentre of healing. Looking at the more personalised treatment seen in the asylums using the ideals of moral therapy, we can therefore gain insight into how modern dementia care would improve through drawing examples from their design.

Throughout this investigation, I will examine qualities, both good and bad, from my chosen case studies, in order to put forward suggestions for the innovation of dementia ward design, which future architects can both learn from and be inspired by. As in Victorian asylums, patients would not have been separated based on illness, and much of the knowledge we have today would not

8

9

Introduction

have been able to be used to classify illnesses, it is not possible to specifically look at the care of dementia patients (Stella Andrews, 2017, p.244). I therefore chose to look at the broader population of mental health patients at the time. I will be scrutinising both Victorian and contemporary structures in order to find what aspects of the Victorian asylum might need reviving, how the needs of cancer patients at Maggie Centres and those of dementia patients might be the same, and thus what properties of the former could be introduced to dementia ward design.

10

Fig. 2 Campus for Ageing and Vitality

11

NHS Modular Ward Chapter 2

12

NHS Modular Ward

The deinstitutionalisation of the asylums, occurring in the mid 20th century, moved care for patients to community mental health services, resulting in the setting up of psychiatric wards attached to NHS hospitals. The assimilation of mental health patients back into the community, and the caring for them in hospitals, as one would with a physically ill patient, contributed to the destigmatisation of mental illness. When previously patients were housed in isolation, away from the cities and the public eye, it was implied that they were something to be hidden, and perhaps even feared (Leff and Warner, 2006, p.63). Now they were shown to be normal citizens, that one might come into contact with in everyday life. It was now also easier for patients to receive visitors, due to the closer proximity to their loved ones. Thus, a geographical and systematic shift in care had produced a shift in public opinion. Mentally ill people were no longer associated with the asylums, and therefore with their dark and unpleasant reputations (Leff and Warner, 2006, p.63).

However, Julian Leff and Richard Warner argue (Leff and Warner, 2006, p.68) that the design of the wards had not been specific enough to create a healing environment for the care of a mental illness. The NHS architects chose to use a modular design for all wards, as this would be the most economically efficient method.

They based this decision on the belief that any component of

13

NHS Modular Ward

medical care, from a maternity to a geriatric, would require similar functions from their ward. Psychiatric care, perhaps above all, is particularly unique, however, and therefore requires more specialisation in the design of the locus of its provision. A key difference is that the bed is not the place of treatment in psychiatric care, but rather is simply a place to sleep. Unlike in other parts of medicine where care and rehabilitation is centred solely around the bed, ‘treatment occurs in other spaces on the ward – spaces that can be used for recreational and occupational activities, for socialisation and for individual and group treatments’(Leff and Warner, 2006, p. 68).

Castleside ward is a ward for elderly people with dementia at the Centre for Health of the Elderly, Campus for Ageing and Vitality, Newcastle (NHS, 2016). Most people with dementia will receive treatment and care in the comfort of their home but for some elderly people this care is best administered in hospital. Patients can stay on the ward for months at a time, so a variety of different specialist are needed on the ward to tackle the many difficulties of dementia, such as podiatrists, occupational therapists, pharmacists, arts therapists, psychologists, speech and language therapists and social workers(Tyne and Wear NHS Foundation Trust, 2019). The ward has 10 beds and was originally built to be a maternity ward (Tyne and Wear NHS Foundation Trust, 2019). This

14

NHS Modular Ward

Fig. 3

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NHS Modular Ward

is evident from the concentration of the design on its functionality rather than its atmosphere, which I witnessed upon visiting the ward on the 6th December 2019 for research purposes.

The patients’ bedrooms were very basic with minimal decoration.

Furnishings consisted of a bed, a bedside table, and a cupboard.

Some of the rooms were only just big enough to fit a chair next to the bed in order to accommodate a visitor. According to NHS guidelines for dementia ward design, the bedrooms should allow for the bed to be placed in two positions, either the bed with two or one sides against a wall (Department of Health and Social Care, 2015, p.36). This wasn’t possible in some of the rooms.

Dementia patients who stay in long term inpatient facilities for long periods of time frequently experience reduced exposure to sunlight. This can lead to Seasonal Affective Disorder (SAD), which shares many of its symptoms with clinical depression, as well as to a disruption in their circadian rhythms, resulting in sleep disorders such as insomnia, sundowning syndrome, and irregular sleep patterns (Department of Health and Social Care, 2015, p.27). While all the rooms at Castleside had windows to let natural light in, at the time of my visit at 14:30 they were only dimly lit by natural light, and clinical artificial lights were necessary in order for a room to be useable. Furthermore, in many of the rooms windows were

16

NHS Modular Ward

Fig. 4

17

NHS Modular Ward

blocked by a brick wall, preventing the already minimal natural light from entering the room. This can be seen in fig (3).

As well as having a close proximity to natural light, dementia patients should be close to nature. An increased amount of contact with nature has been proven to improve the lives of dementia patients dramatically by calming them down and reducing their tendencies to be aggressive and agitated. Thus, making the patient easier to look after, require less medication, and in turn making the carer’s job easier. As a result of the patients becoming calmer, less possibly harmful medication needs to be prescribed (Eggert et al., 2015, p.6-7). In an independent study carried out by Sube Banerjee for the government, it was found that, as a result of the use of antipsychotics to control the behavioural symptoms of dementia, each year 1,800 die and 1,620 have cerebrovascular adverse events, such as a stroke (Banerjee, 2011, p.3). Furthermore, if a dementia patient’s access to nature and the outdoors is too greatly restricted, they can experience problems related to reduced vitamin D, and insufficient exercise can then lead to an increase in physical effects such as likelihood of obesity, diabetes, heart disease, and strokes, as well as psychological consequences, such as stress, increased wandering, and low morale (Department of Health and Social Care, 2015, p.46). As a result, the Department of Health advises that a close connection with nature, both visually

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NHS Modular Ward

Seating Uneven Ground, Path and Tiles Familiar Objects

Illus.1

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NHS Modular Ward

and physically, be incorporated into the architecture of dementia wards.

In the Department of Health’s guidelines they state that the garden of a ward should; ‘include well-defined pathways, free of obstacles’, as dementia sufferers often have a reduction in their sense of balance (NHS, 2017), be ‘free of… complex decision points’ to prevent patients becoming confused or agitated, and ‘use appropriate contrast for paths, furniture and planting’ as dementia can make it harder to differentiate between colours (NHS, 2017).

Ward architects should also place familiar objects in the garden to make patients feel at ease and to prevent patients from feeling disorientated, such as ‘a shed…, tables and chairs for eating and having afternoon tea, a clothesline’, and ‘provide seating and covered rest areas’ (Department of Health and Social Care, 2015, p.31), to allow for elderly or less mobile patients to pause if they become fatigued ,or to allow them to sit and take in the nature.

The Castleside ward’s garden has only one pathway, and therefore no ‘complex decision points’, however the ground was extremely uneven, to the point of patients being unable to walk on it. This is undeniably a major ‘obstacle’, and prevents the use of the garden for less mobile patients. (Illus.1). Assistance would be needed for elderly patients to navigate the uneven path, and with nurses unlikely to be available for this sort of activity, they are therefore

20

NHS Modular Ward

left unable to use the garden and therefore with restricted time outdoors. Furthermore, the path’s red rubber has faded to a dark maroon, and so isn’t an ‘appropriate contrast’ to ensure patients with affected eyesight see the direction of the path, the furniture also having this issue (Illus.1). Castleside does adhere to some of the guidelines, however - there was plenty of seating and tables for patients to rest or have afternoon tea at, and the rubber material of the path is a safer choice of material than, for example, paving in case a patient was to fall.

The inability of patients to use the garden alone also contributes to the common feeling of dementia patients that they have lost their independence. It is key in care of the elderly that their independence and mobility is maintained to prevent accelerated, irreversible ageing. The Department of Health recommends the provision of en-suite bathrooms for each patient in order to prevent this loss. This addition has other positive effects, including allowing patients greater privacy and dignity, making them feel more at home, reducing the workload of nurses, and reducing the risk of accidents by having toilets in greater proximity. The most likely place for a dementia patient to have an accident is on the way to the toilet in the middle of the night. The addition of an en-suite bathroom, with accompanying lighting for improved visibility, reduces the likelihood of these accidents happening.

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NHS Modular Ward

Despite these recommendations, and clear positives, only one in ten rooms at Castleside had an ensuite.

There are many challenges to moving a dementia patient into a ward or care home, Lisa Deering explains one of the key problems for architects:

‘Once a resident enters the centre, they are leaving an environment which they are familiar with and one of the biggest complications with dementia is confusion.

It is a lack of understanding of the environment and changes that often leads to the other symptoms, such as frustration and aggression’ (Morris, 2019) The issue of a patient not feeling comfortable in their new, alien surroundings can lead to an increase in their behavioural symptoms. This medical problem directly results from the built environment, and it is therefore the responsibility of the architects to attempt to solve the problem through attempting to create a domestic atmosphere. One possible route is modelling the ward on a home by allowing personalisation as far as is possible (Halsall and MacDonald, 2015, p.59). Personalisation can also help with orientation, for example the placement of personal objects outside a patient’s door to signify that it is their room. As important as making the atmosphere domestic is making it non-institutional.

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NHS Modular Ward

Fig.5

Fig.6

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NHS Modular Ward

This, and maintaining a domestic atmosphere, is mentioned many times throughout the Department of Health’s Building Notes, with one of their design principles being to ‘provide a non-institutional scale and environment.’ This shows that they understand the important role that a non-institutional and domestic atmosphere plays in the treatment of their patients.

At Castleside, however, the overwhelming impression I received upon visiting was one of an institution. The ward consists of one, long ‘C’ shaped corridor, with rooms leading off it. There is no personalisation in the corridor to indicate who owns each room – this is signified by a small white board with their name written on (see Fig.5). It is likely that this would be hard for a dementia patient to see with ease. The courtyard also felt institutional and unnatural – it was surrounded on all sides by two-story buildings, as can be seen in Illus.(1). These overlooking buildings mean the courtyard lacks privacy and feels claustrophobic. Some attempt has been made to nurture a domestic atmosphere in one corner of the kitchen, with book shelves, a large painting, and a fireplace with chairs and a table, (Fig.6). The most effective part of this domestic corner was the fake fireplace. When I visited, patients were sat round the fireplace and warming their hands and feet as if it were real, creating both a sense of community, allowing the patients to socialise, and domesticity. When I visited it was just

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NHS Modular Ward

before Christmas, so the nurses had put up a Christmas tree with some Christmas decorations. This corner glowed with a feeling of comfort and relief compared to the rest of the sterile ward. The picture (Fig.6) that I took of this corner looks as though it could have been taken in any family home’s sitting room. While this corner has clearly been effective, it is simply a nod to the recommendation that the environment should have a homely feel, with the rest of the ward remaining unchanged in this way. In order to provide the upmost care for dementia patients, the whole of the ward should have been designed in this way to provide the necessary healing environment.

When focussing on its application to dementia care, I believe the NHS modular ward prioritises health and safety and cost in its design, rather than creating the best atmosphere for dementia patients to receive treatment, as evidenced by the design of Castleside Ward. Even in the smallest details, the NHS ward prioritises sanitation due to its necessity across all medical practices, rather than considering the specific needs of individual wards. Castleside’s flooring, for example, is grey and beige vinyl throughout the corridors and rooms. (Fig.4) While this is effective in allowing them to be easily cleaned and in preventing the spread of germs, this also eradicates any domestic feel, replacing it with an institutional atmosphere. This is one of the key points laid out

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NHS Modular Ward

by the Department of Health:

‘Healthcare facilities should provide a therapeutic environment in which the overall design of the building contributes to the process of healing and reduces the risk of healthcare-associated infections rather than simply being a place where treatment takes place.’ (2013, pg.27) While it is important to design with health and safety in mind, particularly in a medical environment and when in close proximity to the elderly, who likely have weaker immune systems, greater care could be taken to reach a compromise to ensure this does not jeopardise the healing environment created within.

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Fig.7

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Drivers of Change Chapter 3

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Drivers of Change

‘The symbolism was impossible to ignore: a façade of care concealing a black hole of neglect’ (Jay, 2016, p.39) Bethlem, the most famed of the pre-rehabilitation asylums, is perhaps the epitome of this idea of asylums. Its façade was ‘modelled off Louis XIV’s Tuileries Palace in Paris, with Corinthian columns, royal arms carved in stone and swagged with garlands, and a central balustrade leading up to an octagonal turret crowned with a shining cupola’ (Jay, 2016, p.38). However, this level of grandeur did not continue into the building. The structure was too week to even hold up the weight of the façade and so began to bend, an unwitting metaphor for the cruel conditions and lack of care given to largely lower-class patients within failing to fulfil the expectations of the ostentatious, mismatched exterior. This bending in the structure created huge cracks in the walls that allowed rainwater to make its way in. Imperfections in the structure continued below ground level; there were no foundations. The brick walls only continued six inches underground and were constructed on ‘waste ground beside the old Roman City wall’ (Jay, 2016, p.39). The palace-like façade was supposed to show to the world that they were caring for the ‘mad’, whereas in reality it was merely a wall to conceal them from the public, in order to be forgotten, the apparent decadence removing any public guilt that might be felt if the cruelty were more overt.

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Drivers of Change

Before the 18th Century options for the mentally ill were limited; either they would live with their families, attempt to survive on the streets, or be subjected to the conditions in Bethlem (Jay, 2016, p.43). Medical knowledge was poor, and therefore the aid provided for sufferers was ill-informed and, often, simply incorrect.

The practices that became the established treatments for mental illnesses therefore had no scientific grounding, and included seasonal bloodletting, blistering, cold showers, and purging. It was widely thought that ‘madness’ was the ‘constant state of a person’ as opposed to a ‘temporary condition’ (Edginton, 1997, p.92).

Treatment would therefore have been thought futile, resulting in a lack of investment, both in time and money, on adequate care and environment. Prison-like structures were built to contain and exclude, comparable to Bethlem or asylums built under the French monarchy (Jay, 2016, p.92). However, around the turn of the century opinion about mental illnesses and how a patient should be treated was changing, and with it the architecture of these institutions. Slow but tangible shifts in public opinion from the 17th to 19th century did much to improve the design of asylums, eventually leading to the York Retreat.

The successful treatment of King George III’s mental illness in the early 1800s was a widely publicised process which did much

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Drivers of Change

Fig.8 George III being irritated by his son before he was cured

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Drivers of Change

to improve understanding of the ability of mental illness to affect anyone, irrespective of class, gender, or education. Royal physicians, who chose to use the established practices, such as bloodletting, were unsurprisingly unsuccessful in their efforts.

While a lower class, poor ‘lunatic’ would likely have continued to be subjected to this ineffective treatment within the confines of an asylum, the King’s status meant that after eleven weeks of failure a new technique was attempted. Reverend Dr. Francis Willis used a form of moral therapy that involved ‘a mixture of moral boosting and strict discipline’ (Jay, 2016, p.60) at his own asylum and so applied these same practices on the King. The evidence was clear to see by the public – humane and compassionate treatment had been more effective than the cruelty that had been excused as healing for so long.

The improvement in George’s condition resulting from this strengthened the growing notion that ‘madness’ might be a curable illness. 18th Century philosopher William Battie had argued this point in his work ‘A Treatise on Madness’. He believed in two types of madness: ‘original madness’ and ‘consequential madness’. ‘Original madness’ was a condition one was born with, and therefore an incurable aspect of a person’s mind. However, ‘consequential madness’ was acquired at some point in a person’s life and was curable (Battie and Monro, 1962, p.20). More

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Drivers of Change

widespread belief in this idea meant growing belief in the worth of investing in mental health care.

Battie also raised the issue of the design of asylums, arguing that the mentally ill should not be treated as criminals. Indeed, a 1744 Act gave Justices the power to have ‘lunatics’ ‘locked up in some secure Place and…chained’ (Fessler, 1956, p.56). Battie rather proposed that ‘remarkable results could be achieved in cases of consequential madness when the proper environment was created’ (Jay, 2016, p.56). Further, John Locke’s 1690 suggestion that insanity was caused by ‘the mis-association of ideas’ disputed contemporary thought that ‘madness’ was a somatic illness, rather than one of the mind (Locke, 1997, p.354-360). Though his ideas had little effect at the time of writing, the therapists of the 19th Century gave them greater consideration, ultimately concluding that mental illness was not somatic, and therefore could not be cured by the traditional somatic remedies.

Locke went on to write that these ‘mis-associations’ were caused by a patient’s environment (Locke, 1997, 354-360). This idea was used to justify removing a patient from ‘the environment and community that had caused these incorrect associations’ for their own good, and their subsequent placement within a new one, ‘which could re-educate and, thereby, rectify errors within their

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Drivers of Change

thought processes’ (Hickman, 2005, p.48). It ‘became orthodoxy’ in the 19th century that asylums would be built in the countryside, away from the artificiality and intensity of the city (Porter, 1990, p.155). This evidences a significant improvement in medical care in itself – a greater consideration of the needs of the ill, rather than of the rest of society. One of the most significant changes was the environment they were allowed to exist in. The government’s attempt to create this controlled environment was the building of asylums, the passing of the 1808 County Asylum Act enabling ‘county authorities to provide an asylum’. (Smith, 2007, p.1) These beliefs were important to the development of asylum architecture, specifically of The York Retreat, because without them the purpose of the architecture would have been not ‘to heal’ but ‘to confine and separate’ (Edginton, 1997, p.92). Had both medical and widespread public belief not changed, I believe the enduring central aspect of asylum architecture would be concerned with it’s outward perception, as in Bethlem, rather than a healing environment within. Largely, the change in architectural focus follows that of contemporary beliefs – just as emphasis transformed from keeping the rest of society safe to the healing of the patient, their design transformed from their perception – the outer - to their utility – the inner.

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Fig.9

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Moral Architecture at the York Retreat Chapter 4

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Moral Architecture at the York Retreat

The York Retreat became so prominent throughout the 19th Century that it influenced asylums not only across the UK, but also in Europe and as far as the USA (Markus, 2005, p.35). It was at the forefront of innovation in psychiatric treatment, namely through its championing of the process of moral therapy. Such advancements brought treatment for the mentally ill into the 19th century, encouraging the 18th century’s somatic treatments to fall into disuse. Moral Therapy encompassed the use of social interaction, strict routine, and design, to treat the mentally ill.

Moral therapy was so strongly at the core of The York Retreat that its ideals were woven into its architecture, creating ‘moral architecture’ in doing so (Edginton, 2003, p.106).

Though moral therapy had indeed been created and applied elsewhere previous to its introduction at the York Retreat, here was the first instance of its realisation in physical form. At the York Retreat the concept that the built environment could affect the healing of a patient came to the fore, and it was this philosophy, rather than the specific design of the Retreat, that was particularly revolutionary in asylum architecture, and which would become increasingly influential throughout the 19th Century (Markus, 2005, p.100).

The individual circumstances of the conception of the York Retreat

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Moral Architecture at the York Retreat

led to the birth of its unique form of moral therapy. Both the Retreat’s founder, William Tuke, and its architect, John Bevans, were Quakers. These men, the most influential in the Retreat’s formation, combined their Quaker values with the previously established practice of moral therapy. Edington’s description of the Retreat’s form of moral therapy evidences this, with two of the four main beliefs overlapping heavily with existing Quaker beliefs (Edginton, 2003, p.105-106). The first of these co-ordinating beliefs was the understanding that the mentally ill were human, and therefore should be treated accordingly, in common with the Quaker belief that every person has an ‘inner light’ of God with them, and therefore should be treated accordingly (Markus, 2005, p.92). The second Quaker value to be integrated into moral therapy was the importance of the family unit. The asylum became a reflection of this ideal: the patients were children of the asylum, the superintendent a father figure, matron as mother figure, and the asylum as the family home (Taylor, 2011, p.203). Tuke believed that if patients could be re-taught how to behave and socialize in a family environment, through the safe and controlled setting of the Retreat, they would then be able to re-assimilate into contemporary society and the real family home (Edginton, 1997, p.98).

Becoming a part of the ‘Quaker family’ also meant leading a

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Moral Architecture at the York Retreat

‘simple controlled’ Quaker life, this being combined with the strict daily routine of moral therapy (Edginton, 1997, p.96).

Both were used to distract the patient’s minds away from their disorder and to refocus their attentions onto both the built and natural environments surrounding them (Edginton, 1997, p.97).

For example both the men and women were given occupational jobs, which they were able to carry out in the environment of the Retreat. The women were given jobs such as; ‘polishing furniture in their gallery, assisting in the kitchen, churning butter or mangling clothes’, alternatively the men ‘pumped water, chopped wood or cleaned shoes’ (Digby, 1985, p.42). There were also multiple sports on offer for patients, both offering mental distraction and physical activity, such as cricket, croquet, and horse riding (Edginton, 1997, p.97).

The third value of the York Retreat, as defined by Edington, was to not use the medical therapies of the day. These were mainly based off the science of humours, which had been the leading medical approach to curing the mind in Europe for many centuries. Instead moral therapy promoted the use of psychological and non-medical treatment.

The final and most unique part of moral therapy at the Retreat was the use of the Retreat’s environment, both built and natural,

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Moral Architecture at the York Retreat

as part of the treatment process for their patients. Both Bevans and Tuke understood the substantial impact that architecture and nature would have on their patients, and thus placed great import on this aspect of the Retreat’s creation. When designing the Retreat, they aimed to create an environment that would nurture a new set of behaviours in their patients, thus enabling them to become a rational and ‘normal’ person (Markus, 2005, p.100).

This innovative interweaving of design and healing led Bevans to create a piece of architecture with a different image to previous asylums. As explained by Edginton:

‘The design incorporated the image of a healthy life and the material means by which it was to be achieved. It did not reflect the particular qualities of insanity or the prevailing ideas that separated the workings of the mind from the experiences of the body.’ (Edginton, 2003, p.110) Instead of concentrating on representing the mental state of the patients when they entered the asylums in the architecture, they focused on creating a feeling of hope and optimism for the journey the patients were about to embark on. This would embody the reformed minds of patients who had passed through and had been healed.

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Moral Architecture at the York Retreat

Fig.10: Aerial view of the Yok Retreat

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Moral Architecture at the York Retreat

The integration of the values of the Quaker family in the Retreat’s treatment processes also permeated into the architecture, contributing to the creation of its unique ‘moral architecture’.

The users of the asylum were to be a family, and so Bevans communicated this message through the architecture (Edginton, 2003). The retreat was designed to resemble a typical Georgian family house, in the hope that it could become a ‘surrogate home’ for its patients (Digby, 1985, p.38).

Further to this domestic aspect of the Retreat, Bevans did not want the Retreat to appear institutional (Jay, 2016, p.94). Again, the architecture being intended to embody the ethos of the treatment. The Retreat rejected the treatments used by the medical institutions of the day and therefore wanted to avoid any resemblance with these institutions, in order to reflect their differing ideals.

Comments in the ‘Visitors’ Book’ clearly evidence that the aim for an anti-institutional, domestic atmosphere had succeeded, and spread to the design of the interiors of the Retreats, with several comments describing a homely feel (Edginton, 1997, p.97). Comments particularly note the design of the rooms, furniture, and windows, as well as the overall atmosphere. This healing atmosphere was initially created and then effectively

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Moral Architecture at the York Retreat

Fig.11: Window of the York Retreat

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Moral Architecture at the York Retreat

maintained through a combination of carefully considered design features. The window design is a particularly appropriate example.

Windows in traditional institutions, such as hospitals and older asylums, would often have no glass and use bars to keep patients in, giving them little protection from the elements and evoking images of imprisonment and criminality (Digby, 1985, p.39).

Conversely, windows at the Retreat were designed to look normal, yet at the same time providing the security necessary for such an establishment (See fig.11). The windowpanes were eight by six and a half inches square, designed to prevent a patient from breaking a pane and squeezing out through it. An added bonus was that it also made the panes cheaper to replace (Digby, 1985, p.39). While the windows did have bars on them, they were explicitly devised to be invisible, through concealment within the wooden frames of the windows.

The doors of the Retreat, while also a smaller architectural detail, were also paid much attention. The doors of traditional institutions were locked with bolts at night, which would create the harsh sound of the mettle sliding shut, reminiscent of a prison (Stark, 1807, p.7). To tackle this problem the bolts were coated with leather, and after some time these were then replaced with mortice locks (Tuke, 1996, p.32-3). To prevent patients from being able to barricade their doors, they were made to open outwards.

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Moral Architecture at the York Retreat

It was also key in the design of both the doors and the walls that they would prevent the travelling of sound – they would need to be thick enough to prevent the noise of one patient penetrating the area of his neighbour, and thus affecting his environment.

The design considerations of the windows, doors and walls were all carrying out the same function: to preserve the healing environment of the asylum. This was achieved either through maintaining the domestic atmosphere or preventing other patients from disrupting the healing environment. As well as the design of the Retreat, the managing of it through the categorising and control of patients also contributed to the preservation of the healing atmosphere. The Retreat split patients up based on how disruptive they were to the healing environment, and on how rational their attitude and behaviour was. They did not take what type of illness they had into account (Edginton, 1997, p.96).

This is unlike modern-day hospitals, which categorize patients by illness to allow them to ‘create a taxonomy of madness’ (Edginton, 1997, p.96). This illustrates the differences in priorities in care provided by the Retreat and by the hospitals of today. An integral part of the Retreat’s care was the environment of the asylum and it was therefore crucial for the patient’s recovery that this was maintained. On the other hand, the care administered in the modern dementia ward relies more on drugs than it does the

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Moral Architecture at the York Retreat

environment of the ward (Edginton, 1994, p.380).

The healing environment also included the nature that surrounded the Retreat, and thus a similar amount of attention went into the design of the Retreat’s gardens as the architecture. This is evidenced by the numerous walks, wooden glades, gardens and orchards at the Retreat for patients to enjoy. 300 trees were also planted (Edginton, 1997, p.94) before the Retreat had opened, and its land was increased from 11 acres to 27 acres (Digby, 1985, p.43) during its time. A patient’s proximity to nature is key in the administration of moral therapy (Edginton, 1997, p.95) and is still heavily involved in dementia treatment today. Research has shown that integrating nature into dementia wards, thereby allowing patients to encounter nature more often, improves the lives of everyone involved in the ward, both care givers and receivers.

Primarily it improves the lives of patients, with some of the effects of dementia being reduced with increased exposure to nature, for example agitation and aggression. Patients can therefore require lower doses of medicine, achieving a greater quality of life as these medicines can be harmful to the body (Eggert et al., 2015).

Secondly, as a result of the patients being calmer it is easier for the carers to look after them, and more enjoyable for loved ones to come and visit (Eggert et al., 2015, p.28).

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Moral Architecture at the York Retreat

The York Retreat became widely recognised for its higher rates of recovery (Thurnam, 1845) and as a result other asylums tried to replicate its healing process. However, there were few that managed to successfully replicate the Retreat, due to the considerable amount of committed staff who would be prepared to devote their entire lives to caring for challenging patients that was required (Jay, 2016, p.95). It was also a lot costlier than the other forms of care available at the time. One criticism that Edginton has of the Retreat is that the environment created does not heal the patients, but merely controls them: Tuke, in his attempts to replicate a type of utopian family by creating the environment for one, set up a type of treatment based on the social reintegration of the insane. This reintegration, of course, was based on control; the more controlled the environment the more controlled the insanity. Control alone, however, neither inhibits freedom nor creates self-discipline. The Retreat did not place the lunatic closer to the calm influence of nature but closer to the influence of a constructed nature‌ On the other hand, the escape of the patient from the anarchy or insanity of life during a period of social upheavals could only be a positive step and a healthy step.’ (Edginton, 1997, p.98) Edginton makes the argument that Tuke had merely taken away

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Moral Architecture at the York Retreat

the literal shackles of the non-moral asylums replaced them with the psychological shackles of his asylum. For patients to stay in the improved mental state that the Retreat had given them, they would need to stay at the Retreat in Tuke’s family. However, Edginton recognises that the respite a patient would receive from being displaced from the environment that may have caused their illness, would have been undeniably positive.

The York Retreat was incredibly influential, with a legacy in both medicine and, in particular, medical architecture. Through bringing attention to the improved methods of moral therapy, and thus discouraging the medical profession from reliance on the science of humours, the Retreat created a lasting impact on the medical world. I would argue that the most influential part of the Retreat, though perhaps not the building itself, was the discovery that the built environment could act as a tool to influence and improve the mood and mental state of some of society’s most vulnerable.

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Fig.12: Faรงade of Newcastle Maggie Centre

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Moral Architecture Today, Maggie's Centres Chapter 5

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Moral Architecture' Today, Maggie's Centres

Maggie’s Centres, though existing hundreds of years after the York Retreat, puts into practice many of its values, clearly agreeing that the architecture of a centre is of great importance. That a 21st century medical building has been able to prioritise this design of its environment in order to facilitate care, can be used as a model for the future architects of dementia wards. The ‘Maggie’s architecture and landscape brief’ is an interesting insight into the ethos of the charity. In it, Jencks sets out what should be the key objectives when designing one of their centres.

‘The building, the landscape, the design of the interior, the art on the walls all give a different dimension and depth to the help and support people derive from Maggie’s. They have a significant emotional impact on those who come. If they raise your spirits even for a moment, they will have done a good job. We know how much more they can do than that. Our buildings must look friendly. They must have clarity.’ (Jencks, 2020, p.4) Jencks’ brief clearly illustrates the high import placed on the architecture of the centres by the charity, and the significant effects Jencks believes this can have on a patient. A centre’s architecture has the responsibility of creating a calming and healing foundation on which a patient might be able to regroup and build hope. Unlike many standard architecture briefs, the “Maggie’s Architecture

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Moral Architecture' Today, Maggie's Centres

and Landscape Brief’ does not set out a list of specific bullet point requirements and requests. Rather, it conveys a feeling and story, the architecture being a medium to interpret this through. Jencks appears more concerned by the ambiance of a centre, describing this through imagined emotional response rather than through a centre’s physicality. This can be more explicitly seen in the following excerpts.

‘We ask the spaces in our buildings and landscapes to allow the people who use them to take charge of how they want to use them. We want to encourage them to make choices’ (Jencks, 2020, p.8)‘ ‘Maggie’s Centres can and should look (and feel) bold and self-confident, as well as inviting and safe. They must look and feel joyous, they must have zest as well as calm.

The impression they must give is “I can imagine feeling different here.”’ (Jencks, 2020, p.7) While Jencks is here stating that the centre should feel ‘bold and self-confident’, through anthropomorphising the structure he is inferring that this apparently only aesthetic feature might also prompt the patient to feel this way.

As a result of this focus on abstract rather than concrete features,

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Moral Architecture' Today, Maggie's Centres

Fig.13: Domestic Staircase of Newcastle Maggie Centre

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Moral Architecture' Today, Maggie's Centres

each centre is vastly different from the next physically. This gives each centre its own unique feeling. One of the key requests from the brief is to give the centre a ‘domestic’ atmosphere and ethos (Van der Linden, Annemans and Heylighen, 2016). I believe the uniqueness of each centre adds to the more homely atmosphere.

In order to feel at home, one must feel proud ownership of a space and it must feel unique to you. The Maggie Centre users express these exact feelings in interviews excerpted from, ‘What makes an environment healing? Users and Designer About the Maggie’s Cancer Caring Centre London’. Users consistently use possessive pronouns when being interviewed about the centres, describing the one they use as ‘mine’ (Van der Linden, Annemans and Heylighen, 2016, p.5). This shows the sense of proud ownership and allegiance users feel about ‘their’ centre, contributing to the domestic atmosphere and perhaps stemming from Jencks’ request in the brief that users can ‘take charge’ of the spaces. This domestic scale and non-institutional atmosphere of the Newcastle Maggie Centre would work perfectly in a dementia ward. Making dementia patients feel at home helps to keep them calm and reduces aggression and anxiety (Department of Health and Social Care, 2013, p.26).

The brief also makes clear that centres should not have an institutional atmosphere, like the Retreat. One simple design

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Moral Architecture' Today, Maggie's Centres

Fig.14: The centre of the Newcastle Maggie Centre, the kitchen table

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Moral Architecture' Today, Maggie's Centres

choice which helps them achieve this is by ensuring the Maggie Centres are no bigger than a large house. This is in direct contrast to a common hospital buildings which they share their sites with, and are often extremely large and thus impersonal. The smaller size also often means that the jarring and cluttered system of signs that is key on many institutional sites is less necessary. Signs tend to imply that a patient is one of many, due to their universality and purpose for mass consumption. The charity points out that you wouldn’t use signs in your own home, and thus that they have no place in the centres – not even for the toilets (Jencks, 2020, p.11). Furthermore, the brief stipulates that there should not be a reception desk, as this would be reminiscent of a hospital. The use of such a system also might allow a hierarchy and create a perceived divide, through empowering those behind the desk, possibly making the visitor feel beneath them.

The reasoning behind the creation of a domestic atmosphere is to attempt and create a healing environment. The meaning of a healing environment is explored in a paper by Van der Linden, Annemans and Heylighen (2016). The authors interview five architects, each from a different Maggie Centre project. They discover that there are four key themes which the architects associate with a healing environment and therefore incorporate into their buildings; nature, spatial experience, domesticity and

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Moral Architecture' Today, Maggie's Centres

Fig.15: Garden of Maggie Centre Newcastle

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Moral Architecture' Today, Maggie's Centres

privacy (Van der Linden, Annemans and Heylighen, 2016, p.512).

Each one of these themes would have a positive impact on a dementia ward.

When I went to visit the Maggie Centre in Newcastle, I saw firsthand how each one of the themes is carefully integrated into the architecture. The building’s footprint was an L shape that wrapped around a central courtyard, placing nature at the centre of the building and allowing each room to have a direct view out on to the courtyard. I believe that this is in direct response to this passage from the brief:

‘Sometimes, all that a person can bear, if they are in acute distress, is to look out of the window from a sheltered place, at the branch of a tree moving in the wind. We would like there to be as many opportunities as possible to look out from wherever you are in the building, even if it is to an internal planted courtyard.’ (Van der Linden, Annemans and Heylighen, 2016, p.8) This emphasis on nature as a key part of the creation of a healing environment would be particularly advantageous in its incorporation into a dementia ward, as this has a significant impact on quality of life. An increased connection with nature can reduce agitation and aggressive tendencies, thereby potentially reducing

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Moral Architecture' Today, Maggie's Centres

Fig.16: The huge windows of the library at the Newcastle Maggie Centre, allowing an amazing view out to the garden and allowing plenty of natural light in to the library

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Moral Architecture' Today, Maggie's Centres

the amount of medication a patient needs and greatly improve their health (Eggert et al., 2015). As well as improving the lives of patients, this connection to nature would have a similar effect on those of the carers and visitors of patients. Firstly, because improved care through the environment would mean patients would be easier to look after, and have an improved mood, and secondly, their own mental health would be increased in the same manner (Eggert et al., 2015, p.28).

Another one of the themes brought up by the architects that is important when designing a dementia ward was privacy. Private spaces are needed to allow patients a sense of security and control over their surroundings – this is particularly important if patients feel they have less control over other things in their lives, such as their illness (Department of Health and Social Care, 2015, p.13).

If they feel too exposed, they can become agitated and anxious.

Private areas are also needed next to communal areas. These would be used to calm anxious or aggressive patients down without disturbing the other patients in the communal room. At the Newcastle Centre there is a mixture of private and communal.

There are two smaller rooms for reading, one of which is connected directly to the main social area. This format would be perfect to use to calm down dementia patients when they are in a period of

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agitation.

I also believe one of the most salient takeaways from this brief is, as well as its contents, its overall style. Rather than creating a rigid, bullet pointed set of instructions and physical requirements, such as the ‘Health Building Note 00-01 General design guidance for healthcare buildings’, an improved format might be that of Maggie’s brief. The brief is inspiring and evidently well thought-out.

Jencks creates a narrative about an idea yet to be built, giving the architect the freedom to create a truly healing space for its users through describing the atmosphere, personality, and feeling that should be created. The result is a building with a vibrant energy and life to it – one that can then be channelled into the user.

Although the Newcastle Maggie Centre and its brief weren’t designed with Dementia patients in mind, much of its brief can be used to inform the architecture of a dementia ward.

Particularly focusing on its philosophy of what constitutes a healing environment; nature, spatial experience, domesticity and privacy, each fully transferable and integral to a well-designed dementia ward. These are the same ideals that the York Retreat’s ‘moral architecture’ embodied. The Maggie Centres show that the Retreat’s ‘moral architecture’ is still relevant today, and can have a real impact on the care of those in need of medical care. That the

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values of moral architecture have been shown to aid in the care of both those with mental illnesses such as schizophrenia in the 19th century, as well as cancer patients in the modern-day, evidences that they would be of use in NHS hospitals, particularly when applied to the specific needs of dementia patients.

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Fig.17: A corridor at the York Retreat

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Conclusion Chapter 6

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Conclusion

The history of care for the mentally ill and dementia patients has been a varied one, with institutions of differing perspectives; psychological, medical, and hybrids of the two. These varying types of establishments all co-existed at points throughout history, evolving in tandem. While buildings of this nature today may not bear a strong physical resemblance to their predecessors, one can feel their influence in the design philosophies. The York Retreat not only showed the medical profession the full potential of a new form of treatment, moral therapy, but also showed architects a new form of architecture, moral architecture. Moral architecture demonstrated how much we interact on a mental level with the built environment and specifically how this can be utilised to benefit those struggling with their mental health, like dementia patients, in their recovery.

The Maggie Centres have embodied the spirit of the York Retreat, providing ‘asylum’ for cancer patients. Patients are offered a community, and a stable environment to facilitate the improvement of their mental state. The York Retreat and the Maggie Centres create a healing environment involving nature, spatial experiences, domesticity, and privacy (Van der Linden, Annemans and Heylighen, 2016, p.512). Multiple aspects of this environment would be beneficial to a dementia patient, and thus should be considered in the design of the ward in which they receive their treatment.

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Conclusion

Ann Braden Johnson summarises many of the issues of mental health care today in her appraisal of the US’s system:

‘What we have not done is to come up with one treatment that will simply, effectively and cheaply meet the needs of all the mentally ill, although that has not been for lack of trying. What we have come up with are costly treatment models that take a long time to bear fruit, require the best possible staff, and do not cure mental illness. But they do take care of the patients.’ (Johnson, 1990, p.180) The design philosophy of the NHS modular ward compared with The York Retreat and the Newcastle Maggie Centre is very different. The former establishments have a unique design and a highly adapted environment for the healing of their user, while the latter was built with a generalised design intended to carry out an array of functions. The architects of the asylums built in the 19th century understood the different environment that mental health, including dementia, patients needed to heal compared to other sections of medicine, while the architects of the NHS modular wards largely overlooked this in their design. (Leff and Warner, 2006, p.68) The primary reason for the NHS having a modular design for their wards is to keep the cost low, which unavoidably must be a central consideration in any publicly funded

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Conclusion

project. Therefore, it could be argued that the York Retreat and the Maggie Centres set an incomparable standard, as both were charitably funded – the more effective ‘costly treatment models’ mentioned above are possible here (Jay, 2016). However, these centres do show what can be achieved when architecture is used to its full potential, with appropriate funding, to help heal the mind, and gives state funded projects something to aspire to and take inspiration from. Evidently, we are still struggling with the same problem as the architects who built the original asylums, in attempting to find an economically viable way of providing good quality care for those that are most vulnerable in the community.

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List of Illustrations Cover Photo: https://www.teepublic.com/en-gb/sticker/3143525-a-picture-of-good-health-vintage-brain-mapping-ill Illus.1: Shows; the seating, uneven ground, path and tiles, familiar objects present in the Castleside courtyard, Source: own Illus. with own photos Fig 1: Lamp Shades in Kitchen of Newcastle Maggie Centre, Source: own photo Fig 2: ‘Campus for Ageing and Vitality’ , Source: https://www.skyscrapercity.com/showthread.php?p=115258321 Fig 3: Photo showing how close the brick walls are to some of the windows, Source: own photo Fig 4: Shows the institutional atmosphere of Castleside, Source: own photo Fig 5: The small sign with a patient’s name on, on their door, Source: own photo Fig 6: The domestic corner of Castleside, Source: own photo Fig 7: William Hogarth’s ‘The Rake’s Progress’, Source: https://www.mirror.co.uk/news/uk-news/bedlams-theatre-madnessmental-hospital-8845687 Fig 8: George III being irritated by his son before he was cured, Thomas Rowlandson’s ‘Piety!’ Source: https://www.rct.uk/collec tion/810287/filial-piety Fig 9: Painting of York Retreat, Source: https://www.blogger.com/blogin.g?blogspotURL=http://hayquaker1.blogspot. com/2010/11/quakers-and-mental-illness-work-of.html Fig 10: Aerial view of the Yok Retreat, Source: http://www.thecardindex.com/postcards/heslington-the-retreat-friends-retreataero-pictorial-ltd/5190 Fig. 11: Windows of the York Retreat, Source: https://historic-hospitals.com/2016/03/12/the-retreat-york/ Fig 12: Façade of Newcastle Maggie Centre, Source: https://www.wallpaper.com/architecture/architect-ted-cullinan-designslatest-maggies-centre-in-newcastle Fig 13: Domestic Staircase of Newcastle Maggie Centre, Source: https://www.archdaily.com/415127/maggie-s-newcastle-cullinan-studio/520a46c2e8e44e80d1000059-maggie-s-newcastle-cullinan-studio-photo?next_project=no Fig 14: The centre of the Newcastle Maggie Centre, the kitchen table, Source: https://www.archdaily.com/415127/maggie-snewcastle-cullinan-studio/520a45aee8e44e8d40000055-maggie-s-newcastle-cullinan-studio-photo?next_project=no Fig 15: Garden of Maggie Centre Newcastle, Source: https://twitter.com/cullinanstudio/status/1049606030517243904 Fig 16: The huge windows of the library at the Newcastle Maggie Centre, allowing an amazing view out to the garden and allowing plenty of natural light in to the library, Souce: https://www.wallpaper.com/architecture/architect-ted-cullinan-designs-latestmaggies-centre-in-newcastle Fig 17: A gallery at the York Retreat, Source: https://wellcomecollection.org/works/f498d6tg

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