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ARCHITECTURE FOR

PSYCHIATRIC TREATMENT
EPFL – École polytechnique féderale de Lausanne
Énoncé théorique for the Master Thesis in Architecture, January 2011

Directeur pédagogique Professor Harry Gugger


Professor Bruno Marchand
Götz Menzel

Students: Benjamin Schütz & Livia Wicki


CONTENTS

INTRODUCTION 7 CHAPTER 4
CASE STUDIES 57
CHAPTER 1
4.2 Relation to society / Expression of building 67
HISTORIC DEVELOPMENT OF MENTAL TREATMENT 9
4.3 Access 75
1.1 Middle Ages 11
4.4 Spatial organisation 83
1.2 From the Renaissance to the French revolution 13
4.5 Window analysis 93
1.3 The end of the 18th century – the moral treatment 16
4.6 Outdoor spaces 99
1.4 The 19th century – construction of the asylum 17
4.7 Impressions of the interior spaces 106
1.5 The early 20th century – decline of the asylum 20
4.8 Conclusion 110
1.6 Deinstitutionalisation 20
1.7 Hospital-village in France – a short intermezzo 21 CONCLUSION OF RESEARCH 112
1.8 Intermediate structures 21
CHAPTER 6
CHAPTER 2 ANNEXE 115
PSYCHIATRY TODAY Visual Material 118

2.1 Mental disorder and society 25 Quotations in original language 120


Thanks 124
2.3 The different treatment facilities 39
2.4 The patient 44

CHAPTER 3
ARCHITECTURE AND PSYCHIATRY 47
3.1 Architecture and the image of psychiatry 48
3.2 Healing environments 50
3.3 Architecture for psychiatric treatment 52
3.4 Conclusion 55
If we take plants as an analogy, some which have been injured
by the vagaries of the weather might well need a sheltered envi-
ronment where humidity, temperature, and light are controlled
in order to recover. If, however, they are retained within this en-
vironment for too long a period, they become «hothouse plants»
and will never be able to face the rigours of normal garden life.

Citation WHO-recommendation,
psychiatric services and architecture, 1959
INTRODUCTION
The present work looks at the Architecture for Psychiatric Treatment.
We are convinced that architecture has a great influence on people, and
that people influence architecture as well. We are interested in the interac-
tion between planned architecture, built space, and the people who actu-
ally use them.
This relationship is of great importance, especially in the field of psychiatry.
A mentally disturbed person perceives his environment differently than a
so-called «healthy person». If the space that surrounds us can affect our
perception, our sense of well being, and our mood, what is then the ideal
environment for a mentally ill person?
In this work we would like to find out the specific needs that the mentally
ill require from their architectural environment. In difficult times patients
are particularly sensitive to their environment, which can contribute to their
well-being. Might the architecture even have an influence on the healing
process of the mentally ill? We consider it a worthy challenge to design a
building that meets the needs of these people.
Additionally, we are interested in the relationship between mental illness
and society. The handling of mentally ill people has changed considerably
over time, which is also expressed in architecture. This will be discussed in
chapter one. A strong stigmatisation against the mentally ill still exists. We
want to find out whether architecture can contribute to the fight against
prejudice and stigma.
Since we have no previous significant knowledge in the field of psychiatry,
our first task is to clarify the basics and to get an overview of the topic. This
includes, for example, the definition of what distinguishes an ill person from
a healthy person and under which cicumstansces someone can become ill.
This theme is discussed in chapter two. The influence of architecture on the
healing process and the current image of psychiatry will be discussed in
chapter three. The case studies form the last part of our work, chapter four,
where we compare four different psychiatric facilities.
Through this «énoncé théorique», we are opening up the large field of psy-
chiatry, with the focus on architecture, and we will use this knowledge to
develop a sound architectural design project in the next semester.

INTRODUCTION 7
CHAPTER 1
HISTORIC DEVELOPMENT OF MENTAL TREATMENT

The History of psychiatry focuses on the handling of mental illness over the
course of the ages. It aims to establish the scientific, social and medical
point of view in this complex matter. The domain can be structured in three
epochs. From antiquity to the end of the 18th century we can talk about
history of madness. History of psychiatry in the strict sense begins with the
Enlightenment in the 18th century, when efforts to systematically care for
the mental ills began. Since the end of the 19th century psychiatry has be-
come an academic science.
In this first chapter we outline the development and evolution of the ar-
chitecture for mental illness. We will look at the ideologies and views that
have motivated and justified the specific architectural form, but address the
medical and scientific point of view just where it is necessary for the under-
standing of the development. This allows us to keep the historical overview
brief and focus on the most important incidents.

CHAPTER 1: HISTORIC DEVELOPMENT 9


1.1 MIDDLE AGES

In the early middle ages psychological issues are seen within a theological and moral framework. Me-
dieval society believes that individuals have free will and are responsible for their actions, but that
illness (including mental illness) comes from sin and results in punishment from God or possession
by the devil. In this line of argument mental illness is seen as either the result of sin or as a test of
faith, and religious activity becomes a frequently used cure. Monasteries start to play an important
role in the caretaking of poor people’s illnesses, but many mentally ill live nevertheless with their
families and are treated at home.
The social position that lunatics occupy in medieval society is hard to identify. On one side there
is a certain degree of understanding towards the suffering that mental illness brings, on the other
hand a process of social regulation is gradually developed. Everybody that is abnormal is contained,
marginalized and excluded.
A certain number of mentally unstable the dangerous ones, are locked up in prisons. This confine-
ment is seen as necessary to be able to maintain the public order. There is a certain fear that the
dangerous lunatics could harm the community, and that their madness could somehow spread. Pris-
ons and other places of isolated confinement are the most common solutions that medieval society
has to deal with aggressive, mentally unsound people.

CHAPTER 1: HISTORIC DEVELOPMENT 11


1.2 FROM THE RENAISSANCE TO THE FRENCH REVOLUTION
The renaissance hospital is a place where different activities are combined: religious rites, assistance,
care, trade and artistic work. Those many functions make the hospital a small city within the city.
The architects put in place a variety of different elements to visualise and reinforce the public char-
acter of those buildings. Arcades, loggias, pronaos, cloister, patios and courtyards, create transition
zones between the streets, the squares and the hospital. In the case of the famous Ospedale degli
innocenti built in 1429 by Brunelleschi, the arcades are not only elements of transition, but they also
generate and regulate the urban space; the square of Santissima Annunziata. 1
When talking about those hospitals and their important role in the urban fabric of Florence, one
could get the impression that the society of the Renaissance era took very good care of their
weak members. But when reading Martin Luther’s precise description of the hospitals in Florence,
it becomes clear that this kind of treatment and the social acceptance was limited to a very small
number of people:
«In Florence the hospitals are built like royal buildings: there is very good food and
drinks for everyone, the servants are very diligent, the doctors very knowing, the lin-
ens and clothes are very clean and the beds are painted. Immediately upon arrival at
the hospital the patient is undressed, and all his clothes are honestly, in the presence
of a notary, put on deposit. The patient is dressed in a white blouse, and put in a nice
painted bed with sheets of pure silk. Just afterwards two doctors are conducted and
later the servants bring to eat and drink in proper glasses, that they do not touch be-
cause they are served on a tray. Then honest women, all veiled, serve during unknown
days the poor and return home afterwards. I saw in Florence with how much care the
hospitals are maintained!» 2

1 Urban implementation of the Ospedale degli innocenti in the city of Florence, 18th Century 1 cf. Architecture et Psychiatrie, p. 18
2 The arcades function as an element of transition between public and private space 2 Cited in C. Marcetti, Abitare la follia, taken from Architecture et Psychiatrie, p.17, see annexe for original
CHAPTER 1: HISTORIC DEVELOPMENT 13
The lesser fortunate face another reality.
In the 16th century, through the increasing urbanisation and the accompanied depletion process,
the number of unattended mentally ill grows. The straying mob is now composed of vagabonds,
prostitutes, unemployed, criminals, idiots and epileptic.
The royal powers of the old Europe tried for more than two centuries in vain to reduce the number
of vagabonds. In 1575 England ordered the construction of houses of correction. The Germans fol-
lowed in 1620 with their Zuchthäuser, and in 1656, under Louis XIV’s regency, the first hôpital général
was founded in Paris. Those General Hospitals never had any medical function, but they were a
place of confinement and of forced work for the poor, the vagabonds and the mentally ill. «Despite
the rough handling of insane in the middle Ages and the Renaissance, their belonging to human society was
undisputed. But in the age of absolutism, madmen were banned from the streets and thus also banned from
public consciousness», notes Blasius. 3 And Muriel Laharie points out, when writing about the «fool’s
towers»: «Their location symbolises a no man’s land both geographically and socially. Placed between the
civilized and the savaged world, on the boundary between the reassuring organization of the city and the
insecurity of the surrounding forest.» 4
During the age of Enlightenment the mentally ill begin to be seen as sick human beings who are
suffering from an illness and have the right to be treated, rather than beastly creatures. Critics on
the living conditions in the houses of correction grow with the philanthropic movement, and the
mentally ill are considered to be victims of this general confinement who ought to be separated
from the criminals.

3 Cited in Blasius, 1989, p. 21, taken from Geschichte der Psychiatrie, p. 238, see annexe for original
3 Urban implementation of the Narrenturm in the outer quarter of Vienna, around 1764 4 Cited in Nouvelle histoire de la psychiatrie, p. 71, see annexe for original
CHAPTER 1: HISTORIC DEVELOPMENT 15
1.3 THE END OF THE 18TH CENTURY –
THE MORAL TREATMENT 1.4 THE 19TH CENTURY – CONSTRUCTION OF THE ASYLUM

Early reflections on the relationship between architecture and caretaking of the mentally ill dates The creation of asylums is based on two assumptions: isolation, which establishes as a therapeutic
back to the late 18th century: The surgeon J.R. Tenon proclaims in his circular of 1785 that «in procedure the removal of the patient from his environment, and the moral treatment, which gives
contrary to the hospital buildings which are for the other sick only auxiliary means, the hospitals for the the alienist the power to exercise his influence over the disturbed mind.
fools have themselves a function of cure […]. The fool should not be peevish during his treatment and Since the first reflections on buildings specifically for the mentally ill, many theoretical works were
during monitored moments he should be able to leave his loge, browse the gallery, go on a promenade and published and often the ill were moved out of prison. Neverthless, the living conditions of the men-
do an exercise that dissipates and that nature commands him.» 5 These kinds of reflections mark the tally ill have hardly changed. Jean-Etienne-Dominique Esquirol, favourite student of Philippe Pinel,
emergence of the asylum, a place dedicated to treat the mentally ill and it is only logical that it is transforms the asylum into a therapeutic community where doctors and patients live together. He
in this period, for the first time, that a «therapeutic value» is assigned to architecture. In the same believes that patients need to be separated from the outside world in order to establish a calming
way that social values will change over time, opinions on the therapeutic values will also change, distance from the distractions that caused their disease. The asylums should be built outside of the
but the discussion on that matter between architects and alienists, respectively psychiatrists, has city on a slope, to benefit from the purity of air and water, and to allow the mentally ill access to
to this day never fallen silent. nature, which was supposed to have a therapeutic influence in itself. Beyond those aspects which
Philippe Pinel, famous for his legendary act of «releasing the madmen from their chains», argues were beneficial to the patients, there were also other important factors involved: the land price
similarly in his traité médico-philosophique sur l’aliénation mentale ou la manie in 1800. Pinel is the was cheaper away from the centres, and it successfully removed unwanted patients from the city,
first to connect madness with the medical as well as the philosophical system. Although there is and thus from society.
no doubt from today’s perspective that the release of the mentally ill was not a singular event but After visiting a certain number of asylums in France, Esquirol hands over his report, Des établis-
a long process in which different actors were involved, one can say that Pinel has been a major sements consacrés aux aliénés en France et des moyens de les améliorer, to the French minister of the
stimulus on the transformation of the whole asylum system, and that the origin of the «traitement interior in 1818. In that paper he includes precise instructions on how an asylum ought to be set
moral» is to be found in that process. up, and accompanies it with a model plan, on which the architect Hyppolyte Lebas elaborates with
The moral treatment recognises that madness is not a simple loss of mind, but a disorder of the his own indications.
mind. This implies that within each patient’s mind reason is to be found, and to be worked with: The The model plan consists of two symmetrical parts: the right for the men and the left for the women,
«reasonable» part of the mind is to be used to cure and eliminate the «delirious» part. separated by a administration building. Each part includes two sets of three living quarters arranged
The buildings for the mentally ill have thus evolved from simple prisons, with the only goal to shut on both sides of three service buildings. The quarters are U-shaped, organised around a courtyard
away the dangerous, to asylums, dedicated exclusively to the mentally unstable and capable of and limited to a single story. Esquirol conducted many reflections on the limitations to one story
providing some kind of therapy. quarters and explains in 1838: «Buildings where the insane are housed on the first, second or third
floor, offer numerous and serious drawbacks. […] windows must be barred in all the quarters to
prevent escape and suicide; and staircases must be barricaded. […] Asylums whose buildings are
constructed on the ground floor have innumerable benefits. […] galleries may stay open; the insane
are less homely and can go outside as they wish …« 6

6 cf. Architecture et Psychiatrie, p. 20, cited there in Des maladies mentales considérées sous les rapports médical,
5 Cited from J.R. Tenon, cited in Nouvelle Histoire de la Psychiatrie, p.119, see annexe for original hygiénique et médico-légal, J.E. Esquirol, Bruxelles, 1838, see annexe for original
CHAPTER 1: HISTORIC DEVELOPMENT 17
This composition allows for not only the separating of the sexes into two distinct parts, but also
for the patients to be divided according to their social status. Deodaat Tevaearai describes in Lieux
de folie, monuments de raison that the asylums have almost always a private unit reserved to paying
patients and situated on the south of the complex. The common patients are classified according
to their degree of agitation. A distinction is made between the quiet, the semi-agitated and the
agitated to which the epileptics are added. The quiet are placed next to the private patients, and
more one moves north, more the degree of agitation increases. Each division has its own confined
garden, which allows patients to get fresh air and move around, without disturbing the patients
with other degrees of agitation. The different services are also arranged hierarchically. The adminis-
tration is located on the south end, while the chapel, the kitchen, the laundry, the boiler room and
the morgue are situated towards the north.
The combination of those three elements – a powerful formula, a critical appraisal and a proposed
organisation of the asylum make Esquirol a valuable reference, both for the alienists as for the
architects.
Although the principles of Esquirol’s plan have been applied on various asylums, the final outcomes
are often very different from the original ideal. Most often the living quarters were extended on sev-
eral floors to obtain more usable space for patients and to implement the project on a smaller plot.
In The architecture of madness C. Yanni points out that the reorganisation of society into sane and
insane was represented by the very existence of those large scale structures, and that architecture
preformed a kind of cultural work through these buildings by making such categories obvious. The
++ construction of a colossal asylum would communicate a division between those inside the walls
(insane) and those outside (probably, but not necessarily, sane).
agitation

public

court-
private
yard
--

4 Esquirol’s theoretical plan of an asylum, 1818


5 Schematic development of an asylum
CHAPTER 1: HISTORIC DEVELOPMENT 19
1.7 HOSPITAL-VILLAGE IN FRANCE –
1.5 THE EARLY 20 TH
CENTURY – DECLINE OF THE ASYLUM A SHORT INTERMEZZO
«Each generation faces By the early 1900s the once popular asylum has lost its prestige. Due to the remote geographical In 1960 the French propose to modernise the old hospitals by building hospital-villages. This type
different mental chal- location, a cosmos of its own has developed where the asylum director is the manager of a big of institution is presented as the ideal hospital: They ask for proximity to a major city, no walls, no
lenges in each phase of
life. In situations with
establishment, rather than a medical researcher. Patients are hardly able to leave the asylums, and fence, maximum two floors, no more than three to six hundred beds and a village square function-
critical life events and as a result the buildings are overcrowded. 7 ing as the social centre, surrounded by medical and administrative buildings. In short, the aim is to
phases of transitions, While alienists still believe in the endogeneity of mental illness and are constantly looking for the mimic society fitted for the mentally ill. Instead of going into town and drinking a coffee, the pa-
people are more vulner- tients go to the social centre of the hospital, the hospital-village has its own church, and instead of
pathogenic part in the human body, the appearance of mental disorders due to a virus reinforces
able to mental disor-
the neurological orientation of psychiatry. The great gap between the asylums with their absence of going to work, the patients participate in occupational therapy. Barely realised, the hospital-village
ders. This is especially
so when difficult life innovation and researchers at university will lead to the emergence and detachment of psychiatry is already considered out-of-date. This type of institution is in reality just another declination of the
events combine with from alienism. 8 19th century asylum, bearing the same problems of segregation due to its distance from society.11
difficult life conditions.
These situations can The idea of taking care of the mentally ill outside of big institutions and thus avoiding a too long
lead to mental crises separation from their environment first became popular in the 1920’s. The belief is that if treating 1.8 INTERMEDIATE STRUCTURES
which endanger mental inside the asylum is not working, perhaps treatment outside would. One of the first institutions that
health and cause mental offered an «open service» was the hospital Henri-Rousselle in Paris. Created in 1922 by the mental Intermediate structures are used where ambulant care is not enough and stationary treatment is
illness.»1 not necessary, or not necessary anymore. It can also offer an alternative to hospitalisation. All over
hygiene league, the hospital housed an acute day ward, as well as a social service and research
laboratories. But despite the fact that the French minister of the interior gives orders to rename the world different intermediate structures exist with different ideas behind them.
the «asile aliéné» in «hôpital psychiatrique», developments of treatment offers similar to the one of The «clubhouse concept», which has its beginnings in the United States in 1984, is modelled after
Henri-Rousselle remain an exception. In 1942 Paul Balvet notes: «the lunatic asylums have changed the Gentlemen’s Club of New York and the concept is very simple: if healthy, wealthy people benefit
name, but reality is still the same» .9 from an oasis in the city, a place to get away from both home and business, why should recovering
mental patients do differently? The aim is to see the mentally ill and to make him see himself as
a person rather than a patient, and to separate his personality from the disease. The clubhouse is
1.6 DEINSTITUTIONALISATION 10 not a treatment centre and hence there are no nurses and no doctors. But it provides daily activi-
ties that prepare people with mental illness to work and live independently, and it offers a place to
The policy of deinstitutionalisation begins after World War II. The basic concept is to loosen up
go during the day. The concept mandates that the clubhouse is never in the same district as the
the interwoven and tight relationship between psychiatric treatment and the big institutions and
mentally ill’s apartment, and therefore the first step towards an independent life is to leave home
to enable treatment not in an isolated environment but close to the patient. Obviously, the new
every morning, to cross the city and to gather new impressions. 12
antidepressant and antipsychotic drugs, which are introduced to the market in the 1950s, have a
After a short period of absolute refusal to send patients to mental clinics, psychiatry has realised that it
great influence on this development since they allow reducing the sometimes heavy symptoms and
cannot treat the mentally ill adequately without the use of a hospital. The new clinic type is the urban
make patients’ treatment within society possible. The drugs help shorten the average stay in the
hospital. It is located in the centre of the city and hence in the centre of community. The urban hospital
hospital, but since most places are lacking after-treatment and rehabilitation, many patients return is not a place of life-long confinement, but it is exclusively used in cases of acute crisis, where use of
to the clinic. This process is critically named the revolving door-effect. It is now apparent that for intermediate structures is not enough.13
too long the psychiatrists concentrated only on stationary and ambulate treatment, but that there
is a need for intermediate structures like day-hospitals, which establish an interface between the
inpatient and outpatient care.

1 cited from: Psychische Gesund-


heit, Strategieentwurf, p. 20, see
annexe for original

7 cf. The architecture of hospitals, edited by C. Wagenaar, C. Yanni p. 433


8 cf. Nouvelle Histoire de la Psychiatrie, p. 430 11 cf. Architecture et Psychiatrie, p. 34
9 cf. Nouvelle histoire de la Psychiatrie, p. 351, see annexe for original 12 cf. The architecture of hospitals, edited. by C. Wagenaar, C. Yanni, p.440/441
10 cf. The architecture of hospitals, edited by C. Wagenaar, C. Yanni p.434/435 13 For more information on modern treatment facilities see part 2.3
CHAPTER 1: HISTORIC DEVELOPMENT 21
CHAPTER 2
PSYCHIATRY TODAY

In this chapter we would like to provide a picture of psychiat-


ric patients, and understand under which circumstances they
become “users” of psychiatric facilities. We address the prob-
lematic relationship between society and psychiatry, which has
always defined the handling of the mentally ill. We will look at
psychiatric treatment by providing an overview of the different
diagnoses, their classifications and the current treatment meth-
ods. Different types of therapeutic facilities, as well as their or-
ganisation within the mental health system, are presented in the
last part.
In 1861, when the mentally ill were still treated in asylums, Wil-
liam D. Fearless wrote:
«We all have some idea of what an asylum would be, and
we hold that as the treatment of the insane is conducted
not only in, but by the asylum, so no architect is compe-
tent to plan the building unless he possesses some knowl-
edge of the treatment of the inmates.»
It is thus our goal to obtain the necessary theoretical knowledge
to enable us to look closely at the case studies and to form a
well-founded opinion of them.

CHAPTER 2: PSYCHIATRY TODAY 23


2.1 MENTAL DISORDER AND SOCIETY
Interaction of exogenous, endogenous and psychosocial Definition of mental disorder
factors in the development of mental disorders
Who decides whether someone is ill or not? How do we know if a person suffers from a mental
disorder or is simply exhibiting a behaviour that might seem strange to us, but is really just a part
of their particular nature?
entire organism cognitive structures In Wikipedia, mental disorder is defined as following: «A mental disorder or mental illness is a psychological
psychotropic substances “software”
alcohol
or behavioural pattern generally associated with subjective distress or disability that occurs in an individual, and
exogenous neurophysiologic processes which are not a part of normal development or culture.» 14
drugs
medication factors endogenous neurochemical processes
“biological” factors etc. This statement demonstrates that the definition of mental disorder is a very subjective matter,
pathogenic bacteria
braintumor
mental and since it depends on value judgements including what is normal and what is not within a cultural
behavioural
etc. disorder
context.
As vague as the definition of mental disorder is, the definition of mental health is equally so. The
World Health Organization (WHO) defines mental health as «a being of well-being in which the indi-
psychosocial factors vidual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and
fruitfully, and is able to make a contribution to his or her community». 15
Mental health can therefore be seen as a lifelong process. In each phase of life we have to face dif-
biography
ferent challenges, which we may or may not feel capable of overcoming.
social relations But mental health is not only an expression of strength, well-being and good mental capacities. It is
society also the capability to accept our own weaknesses and limits, and to effectively deal with them. 16
culture
etc.

14 cf. Wikipedia, Mental disorder


15 cf. WHO, Mental health: strengthening our response
6 Interaction of exogenous, endogenous and psychosocial factors 16 cf. Psychische Gesundheit, Strategieentwurf, p.13
CHAPTER 2: PSYCHIATRY TODAY 25
Psychiatric hospitalisation by 1000 inhabitants, Switzerland 2001 Who can become mentally ill?
The WHO describes mental health as a result of dynamic interactions between biological, psychological, «Each generation faces
10
socio- economic, socio- cultural and institutional factors. Therefore mental health is a complex process that different mental chal-
is, besides individual aspects, heavily influenced by the abovementioned external factors. 17 The susceptibil- lenges in each phase of
life. In situations with
ity of a person to mental disorder depends on many factors such as his genetic disposition, his mental critical life events and
8
condition, and the environment in which he lives. Everyone could be touched by a mental disorder, and phases of transitions,
in fact, it is very common in our society. National and international studies 18 from the seventies to the people are more vulner-
nineties showed that almost every second person meets the criteria of a mental disorder at least once able to mental disor-
6 during his lifetime. ders. This is especially
so when difficult life
People who are confronted with a change in their life situation or who face a difficult challenge events combine with
have a particularly high risk of being affected by a mental disorder. Major life transitions such as the difficult life conditions.
4 start of school age, adolescence, entry to professional life, retirement, divorce, professional failure These situations can
lead to mental crises
or experiences of violence can all generate psychological problems. The risk of becoming ill rises if which endanger mental
several factors are present. health and cause mental
2 illness.»1
As we can see in the graphic on the left, young adults between the ages of twenty to twenty-five
years face the highest risk of experiencing mental illness. This is often a time of instability and
many life changes. After this critical age, the risk of a hospitalisation decreases constantly until
0
the age of sixty-five, when the third stage of life begins. The increased number of hospitalisations
-90
-50

-60

-80
-70
-40
-30
-20

-95
-65

-85
-45

55
35
25

75
15

(age)
0

+
5
6-1
0-

96

and decreased reports of wellbeing by people who are older than sixty-five years can be explained
11-

21-

31-

51-

71-
41

66
46

61

81

91
26
16

36

86
56

76

by physical problems, which have an impact on their mental well-being, the loss of loved ones and
suffering from diseases such as Alzheimer’s.
Reported mental well being in % of men and women, Switzerland 1997
(%) 80
Why do more people now suffer from a mental
illness than in the past?
70 There are various opinions on the reasons for the growing number of people who seek psychiatric treat-
60
ment. Some people believe that the sources of the problem are new environmental stressors, such as
quick changes, pressure to succeed and unhealthy working environments. On the other hand, ideas
50 about mental health and illness are changing, with more behaviours now falling under the category
men high
of mental illness. What before was seen as a specificity of someone’s personality is today considered
40 women high
a disorder that should be treated. In addition to this development, the huge progress that is being
30 made in the fields of neuroscience and genetics now make the treatment of more and more disorders
women low
possible. For those diagnoses, the number of cases has not necessarily grown. Rather, behaviours that
men low
20 were once considered unchangeable parts of their personalities are now recognized as a mental ill-
ness, and thus handled with treatment. As a consequence, the number of handled cases has increased.
10
15-24 25-34 35-44 45-54 55-64 65-74 75+ Total (age)
We can say that the growing psychological strain, the improvement in evaluations, and the higher 1 cited from: Psychische Gesund-
demands on health have all contributed to the quickly growing number of psychiatric treatments. heit, Strategieentwurf, p. 20,
see annexe for original

7 Psychiatric hospitalisation in Switzerland 17 cf. cited from WHO, Mental health: strengthening our response
8 Menatal well being in Switzerland 18 cf. Psychische Gesundheit, Strategieentwurf
CHAPTER 2: PSYCHIATRY TODAY 27
On the handling of mental illness and the problem
of stigmatization
Society in its cultural context has always strongly influenced the handling of the mentally ill. As we
saw in Chapter 1, in some periods of history the mentally ill were locked up like dangerous criminals.
More recently, a better understanding of the illnesses has developed. A new medical science field
emerged and fostered the researchers’ interest in treatment methods.
One might erroneously think that now, after all of the progress that has been made, only one opin-
ion on the handling of the mentally ill exists. In reality however, every psychiatric institution adopts,
within a generally accepted framework, its proper position; it defines the word «patient» for itself.
Is the patient first and foremost a guest, or is it necessary that the institution ignores the patient’s
will in certain situations, in order to improve the patient’s condition? Diverse positions make sense,
since patients need varying levels of care in the different stages of their illness. These different opin-
ions are also seen in the patient- caregiver relationship. In the example of the patient as a guest, the
relationship is rather horizontal, while in the later example a strong verticality is noticeable.
Each psychiatric institution thus represents a bilateral position. On the one hand an image is con-
veyed to the outside. The institution shows to society, to the healthy ones, how the sick are treated.
On the other hand, it also conveys an image to the inside; it takes a stand towards the involved
ones: the patients, visitors and employees.
The number of people that frequent the psychiatric services for all kinds of problems is constantly
growing 19, but psychoses are nevertheless still a lot more taboo than physical illnesses. Despite the
growing interest and openness towards psychiatric problems (especially towards depression), the stigmatiza-
tion of psychiatry and its patients remains 20, and it will likely remain in the future, since seeing a doc-
tor for phobias and depression will always be more difficult than having a consultations for pain of a
limb or problems with digestion. Additionally, mental illness is more frightening than somatic illness.
People can generally identify with others who suffer from cardiovascular disease or cancer, despite
the seriousness of the condition, but when it is a matter of mental illness, people often prefer to
convince themselves that this concerns others only. This thinking maintains the stigmatisation and
worsens the burden on affected people and their families. But these are not the only reasons for
stigmatisation. Compulsory hospitalisation and treatment in locked wards are also highly respon-
sible. In our society, everybody is supposed to have his life under control, and autonomy is highly
valued. Knowing that one out of five patients are hospitalised against their will 21 makes people
fearful and insecure. Prejudices against mental illness can also hinder people in need of psychiatric
treatment from seeking professional care. Psychiatric interventions often come late, when people
are already in a state of acute crisis.

19 See graphic on page 40


20 Geschichte der Psychiatrie, Krankheitslehren, Irrwege, Behandlungsformen, p. 497
21 See graphic on page 30
CHAPTER 2: PSYCHIATRY TODAY 29
Involuntary hospitalisation
To go to a psychiatric hospital is never easy for a patient, and no one goes there because he wants «[…] regarding invalid-
to. Some patients do realise the necessity of their hospitalisation. In the best case the patients ity for psychological
are appreciative that there is a place where they can be taken care of in this difficult situation. reasons: it is difficult to
access it, and perhaps
Compulsory hospitalisations also occur in somatic institutions, but are much more frequent in psy- even more difficult to
chiatric clinics. 22 Almost one out of three psychiatric hospitalisations are reported as involuntary in get out, even when you
Switzerland. Compulsory hospitalisation occurs in 18.6% of all cases. As graphic 2 shows, it is the feel ready.»1
Admitting authorities
police and the justice system that mandate them. This high number of involuntary hospitalisations
is one of the reasons for the bad reputation of mental hospitals. It is a great challenge for architects
non-medical service to design a building which many inpatients use against their will. The environmental setup has to
(1%) focus even more on stress and discomfort reduction. 23
non-medical other
therapy ( 4%)
(1%) The resulting costs of mental illness
Statistics show that the ambulant and stationary psychiatric care represent five percent of the
legal authority
global health costs in Switzerland. The largest part of the costs caused by mental illness goes into
(5%)
doctor the payment of pensions due to invalidity. The resulting costs of mental illness accumulate up to
(42%) four percent of the GDP. 24 When considering the large amount of money that is being spent, the
police medical
team
need for a continuous treatment plan that focuses on reintegration into society becomes obvious.
(13%) People who were once affected by a severe mental illness can often not cope with the fast rhythm
of the business world any more. We were told in «les ateliers»25 that only a few companies are willing
to take a chance by employing a former patient. Former patients who have the ability to work to
a limited extent are often unable to find a job and remain dependent on the invalidity insurance.
Reintegration, not only socially but also economically, is therefore an issue that should be addressed
on a political and a socio- cultural level and not only within psychiatric institutions.

Conclusion of mental disorder and society


We have seen that the demands on mental health in our society have grown, and that the probability
that someone will or should use the services of the mental health system at least once in his lifetime is
self/ relatives relatively high. Some contradictions which psychiatry has to deal with become visible here. Although
(34%) mental disorders are a common part of our society, there is a strong rejection of psychiatric institu-
tions not only by the population, but also by the ones in need of psychiatric treatment themselves.
Stigmatisation is one of the main reasons that many people do not receive an appropriate treatment
on time. It is important to improve the image of psychiatry in the population in order to reduce
stigmatisation as far as possible. In chapters 3 and 4, we will discuss how this can be implemented
through architecture.

1 cited from: Annual Rapports


2004, p. 4, see annexe for original

22 cf. Bundesamt für Statistik


23 See 3.2 for more details
24 cf. Psychische Gesundheit, Strategieentwurf, p. 48
9 Admitting authorities in the the PUK-BS 25 Protected workshops of the university hospital of psychiatry (CHUV) in Lausanne
CHAPTER 2: PSYCHIATRY TODAY 31
2.2 ON PSYCHIATRIC TREATMENT
In psychiatry, the words «treatment» and «patient» can be misleading because, both terms are often
used in a passive manner, referring to a patient as someone who receives treatment, rather than
playing an active role in the healing process. In reality, the patient has to collaborate strongly and
contribute his own part if therapy is to be successful. Members of the team who work closely with
«patients» and with whom we had the chance to talk to, usually avoid this terms and spoke about
«people » who have to be accompanied during a treatment process.

Diagnosis
Diagnosis by type of institution Three different systems exist to classify mental illnesses: the International Classification of Dis-
eases-10 (ICD-10) of the WHO, established in 1994, the Diagnostic Statistical Manual IV (DSM IV) of
F0 the American Psychiatric Association and the International Classification of Functioning, Disability
and Health (ICF) of the WHO, established in 2001. The most common one is the ICD-10 that provides
F1
codes for all kinds of diseases. 26
F2 To understand how mental illness can, or sometimes cannot, be categorised, we have listed below
the classification of the ICD-10. It will serve as a basis to discuss the problematic nature of diagnoses
F3
and the controversial specialisation of psychiatric hospitals units.
F4
– F0: Organic, including symptomatic, mental disorders (e.g. Alzheimer)
F5
– F1: Mental and behavioural disorders due to use of psychoactive substances
F6
– F2: Schizophrenia and delusional disorders
F7
– F3: Mood / affective disorders (depression)
F8 – F4: Neurotic, stress-related and somatoform disorders (obsessive-compulsive disorder, phobias)
F9 – F5: Behavioural syndromes associated with physiological disturbances and physical factors
(eating disorder, sleeping disorder, sexual disorder)
Other
– F6: Disorders of personality and behaviour in adult persons (e.g. pyromania, schizoid or para-
0 20 40 60 80 100
(%) noid personality disorder, transsexualism)
stationary clinic
– F7: Mental retardation
intermediate structure
– F8: Disorders of psychological development (e.g. expressive language disorder, specific spell-
ing or reading disorder, autism)
– F9: Behavioural and emotional disorders with onset usually occurring in childhood and ado-
lescence
– In addition, a group of «unspecified mental disorders«.

10 Diagnosis by type of institution in Switzerland 26 Bundesamt für Statistik: Nomenklaturen – Internationale Klassifikation der Krankenheiten (ICD-10)
CHAPTER 2: PSYCHIATRY TODAY 33
It is important to note that categorisation might be helpful for the professionals to decide on a Specialised units
possible treatment strategy or for statistic evaluations. But it also bears the risk of a reinforced M. Grandgirard:
There is a big controversy on whether separation by disorders brings more advantages or disadvan-
stigmatization’ rather than trying to understand the individual and his problems multilaterally, the «The CPNVD in
tages to patients and members of the staff. Yverdon-les-Bains has,
patient is labelled with a word or a number. 27
Most psychiatric facilities treat patients of several diagnoses. The economic reality is one of the rea- in comparison to the
As we can see in the graphic 10, depression (F3) and stress related disorders (F4) are the most com- psychiatric university
sons for this. It is not possible to provide specialized units for each mental disorder, since there are
mon disorders in our society. A series of factors influence mental health28. Depending on the diag- clinic Cery of Lausanne,
not enough patients (besides in big cities) from one diagnosis within the catchment area. The other
nosis one factor can be more important than another. In both cases (depression and stress related the advantage that ev-
negative aspect of specialised units is the above mentioned difficulties of categorising patients. erything is centralised.
disorders) it is interesting to note that the relation between individual and society plays the most
Since they often show unclear or several symptoms at a time, disagreement between professionals Patients do not need to
important role. change units. In Cery
is very common. According to Dr. Grandgirard, units do often refuse their responsibility for a patient
and resulting disputes between units occur quite frequently. There are some clinics in bigger cities, it happens quite often,
Multiple diagnosis such as the psychiatric university clinic in Lausanne or the psychiatric university clinic in Zürich,
that the team changes
opinion about how
To explain all categories and their possible treatment methods would go beyond the scope of this that group disorders in specialized units. Structuring the institution for easier organisation, but also to treat a patient. As
work. Therefore we concentrated our studies on how mental illnesses are grouped, in order to un- making treatment more efficient for specialists (more patients in less time), are the advantages of a result patients are
derstand to what extent they can and should be treated in separate units. specialised units. redirected to another
unit, since their condi-
During our research and talks with different psychiatrists and psychotherapist we found out that The medical team that works on one unit benefits when patients of several diagnoses are treated tion seems to fit better
a therapeutic program is put together for each individual. There is no standard procedure for each together. Working with the mentally ill can be very exhausting. A diversity of diagnoses within one in there.»
specific illness. unit brings therefore a welcomed change. 29
In many cases it is not easy to categorise a patient’s problem since symptoms are often not explicit As we were told in different clinics, it certainly makes sense to treat some specific mental disor-
and symptoms of several categories can be identified. ders in specialized units. Patients who abuse psychoactive substances (F1) are usually taken care
There is usually a primary diagnosis and a secondary diagnosis. For example F1 (Mental behavioural of separately. Since their symptoms differ from other categories, specialised treatment methods
disorder due to use of psychoactive substance) and F6 (disorder of personality such as paranoid are applied. Patients with mental retardation (F7) are usually also separated from patients of other
personality). Or F5 (eating disorder) and F4 (boarder-line personality disorder). diagnoses. They seek physical proximity while most other patients need physical distance when
they are not well.
Patients whose mental disorders have strong physical effects, eating disorders, for example, are
often treated in the psychosomatic unit of a general hospital. Another possibility is to treat them
in specialised rehabilitation clinics that provide care for somatic and psychological problems.
Besides all these arguments for and against specialisation, we should not forget that there is a sci-
entific interest in treating patients in university hospitals, where patients are separated by disorder.
Only this isolated environment allows serious clinical research on treatment methods for specific
disorders.

27 cf. Geschichte der Psychiatrie, p. 500


28 See 2.1.2 for further information 29 According to M. Grandgirard
CHAPTER 2: PSYCHIATRY TODAY 35
Treatment approaches30
As we have seen by now, patients can have different symptoms and their causes are often hard to Mrs. Sonja Flick:
clearly identify. These complex situations make it necessary to choose treatment methods for each «Mental disorders can
be treated but often they
patient individually. Below we present some of the common therapies that can be grouped into cannot be healed. It is
four categories. This allows us to get a picture of the treatment, the facility where they are given, therefore the task of our
and the people who are involved. psychiatric facilities to
improve the patient’s
The psychotherapeutic approach Psychotherapy is a form of psychological treatment that uses the
life quality and to help
patient-physician’s relationship to discover the source of unrest, freeing mental functioning and promoting him find new perspec-
healing. There are several types of psychotherapies; the most known and recognized in psychiatry are the tives.»
psycho-psychoanalytic therapy (derived from psychoanalysis), family psychotherapy and systemic cognitive-
behavioural psychotherapy 31. Most therapies are carried out in an office or in the patient’s room.
The physical approach This approach consists of relaxation through massages or other similar ex-
ercises, but physical exercise is an important part as well. A skilled staff member or a physiotherapist
usually accompanies the patient. Common locations are gymnastic halls or the patient’s room.
The pharmaceutical approach The pharmaceutical approach has the goal of decreasing the
patient’s symptoms. The patient’s stabilisation with medication (antipsychotics and antidepressants
drugs) is often the prerequisite to carrying out other therapies.
Ergotherapy A patient learns or relearns activities of daily life by improving his motoric-functional,
psycho-functional and senso-motoric abilities. This method groups together activities like handi-
crafts, playing, pottery, painting, gardening, cooking and other tasks of daily life. Ergotherapists
usually accompany patients on these activities, and they take place in workshops or other spaces
suitable for the relevant activity.
According to the systemic approach, therapies can only be successful if the patient is not taken as
an isolated individual, but rather if all parts of his life are taken into consideration. As a result, the
patient’s environment, including people such as his family, friends and colleagues, also play an im-
portant role. The availability of places where friends and family members can be received is a factor
that should be considered in the planning of psychiatric facilities.

30 cf. Health Search Engine, Current Diagnosis & Treatment in Psychiatry


31 Cited in: Annual Rapports 2006, p. 11, see annexe for original
CHAPTER 2: PSYCHIATRY TODAY 37
2.3 THE DIFFERENT TREATMENT FACILITIES
The field of psychiatry has rapidly grown, and different branches like the forensic, the military or «The statistics on
the pathological psychiatry, were formed. Today, the field of general psychiatry is divided up into psychiatric hospitals
in Switzerland 2001
three age branches to better respond to the respective age-related needs. With the deinstitutionali- list 48 364 stationary
sation process, 32 psychiatric treatment was split up into different institutional types. hospitalisations and
Nowadays, treatment options are no longer limited to stationary care. Since the mid-eighties, in 2 139 semi-stationary
Coverage by type of treatment facility hospitalisations. (...)
fact, the average length of stay in psychiatric hospitals has declined steadily. In return, outpatient
An examination of
acute crisis rehabilitation reintegration prevention and semi-inpatient treatments have gained importance. 33 This is mainly due to two factors. First, 1 343 patients in seven
the entire health care system suffers greatly under financial pressure, and to save money, the length psychiatric clinics of the
of hospital stays are kept as short as possible. Second, awareness has developed that each hospital canton Zürich showed
stationary acute hospital that 44 percent of all
stay separates the patient from his familiar surroundings, and for a successful treatment, the sur-
patients would not need
roundings are of great importance. For these reasons, the psychiatric clinic has been transformed stationary treatment.» 1
stationary rehabilitation hospital into a place of acute crisis intervention, in which patients spend only a short period of time.
In the following paragraphs we will briefly introduce the four types of institutions, and then discuss
the benefits and risks of the above mentioned separation from familiar environments.
day-care hospital
Stationary clinic
day-care centre The stationary psychiatric clinic is a total institution, 34 which means that it cares for the patient
twenty-four hours a day during his stay and plans his daily life in its entirety. Two different catego-
ries exist: hospitalisation for acute care and hospitalisation for rehabilitation. 35
sheltered workshop The hospital for acute care accommodates patients in an immediate crisis. The facility’s main goal
is to stabilise the person as quickly as possible. Due to the elevated suicide risk, acute clinics have
an important security infrastructure.
therapeutic club
The modern hospital is built in the middle of the city. This central implementation does not only
ease the reintegration process of patients, but it is also an important step towards the desired
long-term structures dedramatisation of the clinic. 36
The stationary rehabilitation clinic, on the other hand, sits in most cases outside of urbanised areas
in order to benefit from remoteness and nice scenery. Many private clinics are set up as rehabs, and
ambulatory patients usually transfer to them once their condition is stabilised. In most cases those clinics do
not offer emergency admissions, but rather the patients arrive on referral from their doctor or from
another psychiatric institution.

1 Gesundheitsdirektion des
Kantons Zürich, 2002 cited
stationary intermediate ambulatory long-term in Psychische Gesundheit, Strat-
clinic structure structure 32 See 1.6 for more information egieentwurf, p.42,
33 cf. Annual Rapport 2000, p. 4 see annexe for original
34 Goffman in Asylums, p.XIIV: «A total institution may be defined as a place of residence and work where a large number of
like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally
administered round of life.»
34 cf. Annual Rapport 2006, p. 8
11 Coverage by type of treatment facility 36 cf. Annual Rapport 2003, p. 9
CHAPTER 2: PSYCHIATRY TODAY 39
Intermediate structures
Whenever ambulant care is not enough and stationary treatment is not necessary, or no longer nec- «For patients with seri-
essary, the intermediate structures enter into action. They can also offer an alternative to hospitalisa- ous mental illnesses and
social handicaps that are
RLY AMBULA
tion. In contrast to ambulant care, the day-care hospital is usually not an anonymous office building nowadays treated repeat-
ELDE E TORY
S PEOP
L INTERM
EDIATE where patients come upon appointment to one session, but rather a centre where patients can spend edly in stationary clinics,
ADULT HOSPITAL
&
DREN
CHIL SCENTS their day, where they are involved in a therapeutic program and where they start socialising again. the option of ambulant
LE
ADO and semi-stationary
A large variety of different intermediate structures exist, all with a different focus. In the day-care hos-
facilities is insufficient.
pital, the medical aspect is important and doctors and nurses are part of the team. Some of them are As a result of this lack
organised similar to clinics, but they offer a big advantage in that the patient does not have to give of coordinated services,
up his familiar surroundings during the treatment period, but instead goes home every evening. this category of patient
spends more time in
In the day-care centre, the focus lays on the active reintegration process. The program offers a variety clinics than the average
of therapeutic activities where the patients play an active role. This can be in the form of creative patient, and therefore
group therapy, fieldtrips, garden work, cooking and similar activities. appropriate, efficient and
economic care is not
Sheltered workshops, another type of intermediate structures, offer small working tasks in a protected guaranteed.» 1
Average lenth of stay (days) in stationary psychiatric hospitals environment. Most of the patients are recently released from a stationary hospitalisation where their
days were planned from A to Z. The workshop’s goal is to fill the patient’s suddenly empty days. In
46.80

30.64
53.49

49.36

40.17
50.52

33.65
52.14

58.27

32.33
51.53

33.72
a later stage, the patient relearns tasks that should facilitate reintegration in the traditional labour
market.
Therapeutic clubs are patient’s associations with the main and overall goal to socially reintegrate psy-
chiatric patients to society and to prevent relapses. Activities might be organised by the members,
but casual encounters around a cup of coffee are more common. Professional staff is still present, but
while the patient-caregiver relationship in a day-care centre is vertical, the patient-caregiver relation
in a therapeutic club is completely horizontal.»
When looking at the variety of offered therapies, it becomes apparent that it’s not a simple question
of treating only the proper psychosis, but its «side-effects» as well. The programs of such facilities
Number of hospitalisations
give a patient structure in his daily life, raise his self-esteem, and help him to learn or relearn tasks of
2’445
2’439

3’426
2’438

2’624

2’892
2’345

3’169
2’833

2’759

2’778
2’737

his everyday life. The programs also focus on the social structure of a patient by involving his family
and friends, with the overall goal of enabling a patient to live his life autonomously again.

Ambulatory
An ambulatory treatment is an extra-clinical treatment that does not interfere with the patient’s activities. 37
The treatments consist of consultations with a psychiatrist or a psychologist and are sometimes
accompanied by family or couple discussions. 38 Patients profit from ambulatory consultations at dif-
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 ferent stages of their illness. As many persons frequent ambulatories, good accessibility is essential.
1 cited from: Psychische
They are therefore situated in city centres, close to the clients. Gesundheit, Strategieentwurf, p.
8, see annexe for original

12 Fields of psychiatric services 37 cited in Annual Rapport 2003, p. 12


13 Average length of stay in stationary psychiatric hospital/ Number of hospitalisations 38 cf. Annual Rapport 2000, p. 5
CHAPTER 2: PSYCHIATRY TODAY 41
Long-term structures
Some mental disorders (dementia, autism and mental retardation amongst others) produce so big Dr. Joe Montadon:
impacts, that the patient will never be able to lead a total independent life anymore. Long-term “Nowadays a clinic is
not a hotel, nor a super-
structures accompany those persons over several years. Residential homes and sheltered employ- vised residential group.
ment schemes for long-term patients form those kinds of structures. It is a place to treat
acute crisis, and patients
Advantages and risks should be aware of this
fact. If patients feel too
Given that patients are nowadays quickly released from hospitals, although the continuation of comfortable and if the
therapy is in most cases indispensable, the intermediate structures have become even more im- environment is too luxu-
portant. 39 It is therefore not surprising that in recent years, focus was put on the continuity and rious, they may not be as
motivated to get well and
cooperation between the different caring institutions to prevent patients from slipping through the
leave the comforts and
net. It has also been shown that if patients are released too quickly from hospitals, and if they do security of the clinic.»
not go through further therapy, the recidivism rate is elevated, and thus the probability that those
patients will end up in the hospital again. Good cooperation between the various treatment facili-
ties led to a significant decrease in instances of the so called «revolving door effect». 40
The development of different treatment facilities brings many benefits for most of the patients.
Nevertheless, they can lead to the neglect and marginalisation of those who are disorientated in
view of the complexity and fragmentation of the various offers. A new category of patients has
developed, who receive treatment too late and only in moments of acute crises. For these patients,
the diagnosis in itself is not a discriminatory criterion. The origin of the delay often lies in problems
of access and inadequate guidance to the required resources. Coordination between multiple actors
Number of persons using psychiatric services per year and bad transitions from one establishment to another can be another reason. Collaboration, not
200000 only with primary care physicians and nurses in health centres, but also (if needed) with the police,
patients’ associations and social services, is essential. 41
A strong continuity in care through the many types of treatment seems to be the overall goal. But
150000 a physical discontinuity in the different facilities can also have advantages. The physical separation
of treatment locations makes the patient aware of his therapeutic improvements. The moving from
one establishment to another can be seen as one step forward in the healing process. 42

100000

50000
stationary clinic
intermediate structure
ambulatory
0

39 According to J. Montandon
40 cf. Annual Rapport 2002
41 cf. Annual Rapport 2004, p. 6
14 Number of persons using psychiatric services per year in Switzerland 42 cf. Annual Rapport 2005, p. 8
CHAPTER 2: PSYCHIATRY TODAY 43
2.4 THE PATIENT
What does it mean for a patient to be in a stationary psychiatric hospital? To be a mental patient is to wear a label, and that label never goes away,
The stay in a stationary psychiatric clinic is not an easy matter for a patient or his relatives. The a label that says little about what you are and even less about who you are.
patient is pulled out of his environment and his social network, and he loses the different roles he To be a mental patient is to never to say what you mean, but to sound like
played within society. 43 He finds himself in several humiliating situations due to the loss of a part of you mean what you say.
his personal integrity, which is caused by incapacitation and the loss of privacy. For someone who To be a mental patient is to tell your psychiatrist he’s helping you,
has never been touched by such a situation, it is hardly possible to imagine what patients and their even if he is not.
relatives have to go through.
To be a mental patient is to act glad when you’re sad and calm when you’re
For this reason we would like to conclude this chapter with a quotation from Rae Unzicker. She mad, and to always be «appropriate.»
was an advocate that stood up for the mental health patients’ rights. She describes what patients
To be a mental patient is to participate in stupid groups that call themselves
experience once they are in the mills of psychiatric hospitals. Even if nowadays a big effort has
therapy. Music isn’t music, its therapy; volleyball isn’t sport, it’s therapy;
been made to improve the situation, these statements still have a lot of truth and they help us to
sewing is therapy; washing dishes is therapy. Even the air you breathe is
understand the patients’ situation.
therapy and that’s called «the milieu.»
«To be a mental patient is to be stigmatized, ostracized, socialized,
patronized, psychiatrised. To be a mental patient is not to die, even if you want to --
and not cry, and not hurt, and not be scared, and not be angry, and not be
To be a mental patient is to have everyone controlling your life but you. vulnerable, and not to laugh too loud -- because, if you do, you only
You’re watched by your shrink, your social worker, your friends, your family. prove that you are a mental patient even if you are not.
And then you’re diagnosed as paranoid.
And so you become a nothing, in a no-world, and you are not.» 44
To be a mental patient is to live with the constant threat and possibility of
being locked up at any time, for almost any reason.
To be a mental patient is to live on $82 a month in food stamps, which
won’t let you buy Kleenex to dry your tears. And to watch your shrink come
back to his office from lunch, driving a Mercedes Benz.
To be a mental patient is to take drugs that dull your mind, deaden your
senses, make you jitter and drool and then you take more drugs to lessen the
«side effects».
To be a mental patient is to apply for jobs and lie about the last few
months or years, because you’ve been in the hospital, and then you don’t get
the job anyway because you’re a mental patient. To be a mental patient
is not to matter.
To be a mental patient is never to be taken seriously.
To be a mental patient is to be a resident of a ghetto, surrounded by
other mental patients who are as scared and hungry and bored and broke
as you are.
To be a mental patient is to watch TV and see how violent and dangerous and
dumb and incompetent and crazy you are.
To be a mental patient is to be a statistic.

43 cf. Asylums – Über die soziale Situation psychiatrischer Patienten und anderer Insassen, p. 25 44 Cited from: To be a mental patient, 1984
CHAPTER 2: PSYCHIATRY TODAY 45
CHAPTER 3
ARCHITECTURE AND PSYCHIATRY
Description of a bad experience in a psychiatric hospital, written in 1954:
«Once inside the door of the hospital the patient is usually taken from
an entrance hall to a records department where a member of the staff
will examine his documents. After this he will be escorted down long
corridors where he will see numbers of patients sitting or walking
aimlessly, perhaps exhibiting gross evidence of desocialisation and
eccentricity.
He will see the many beds all alike and the absence of other furnish-
ings, the walls of a dull, uniform institution buff or brown, and the
windows small, high, barred and often dirty. There will be evidence
of locks, and he will hear the keys of his attendants. The ward will
have a stale smell and often provide evidence of the inadequacy of
the sanitary arrangements.
He will be forced to perform even the most private activities where
he can be seen both by other patients and the staff. Within a crowd
of such patients there will be no opportunity to form friendships
with a small group or to feel any drive to identify himself with those
around him.» 45
This quotation is more than fifty years old, and the conditions in clinics
have greatly changed since (just as the scientific field of psychiatry has
changed). But even though the conditions described are not comparable to
current standards, many people still seem to have this picture in mind when
they think of psychiatric facilities.
In this chapter we want to show architecture’s influences on psychiatry’s
image in society, as well as its great potential in transmitting a message. We
would also like to point out the impact that architecture has on the institu-
tion’s users and the factors that deserve profound consideration when plan-
ning a psychiatric facility.

15 From One flew over the cooko’s nest, Warner Bros. Entertainment, 1975 45 cf. part 2.1.4 (on the handling of the mentally ill)
CHAPTER 3: PSYCHIATRY & ARCHITECTURE 47
3.1 ARCHITECTURE AND THE IMAGE OF PSYCHIATRY
As we have seen in chapter 2, 46 every psychiatric institution takes a bilateral position on the treat- the best case, the structure can offer activities and public services to the locals, consequently building
ment of the mentally ill: toward society on the outside, and toward the patients on the inside. The a bridge between the two worlds that have not gotten to know each other. 50
first part discusses how the position regarding society can be architecturally translated and points In an effort to combat stigmatisation, some psychiatric structures have changed their name to
out the potential consequences. «intervention centre» or «psychiatric care,» instead of «psychiatric hospital». This camouflage can
Most people do not know life inside a psychiatric clinic, and opinions are based upon rumours. The have an impact in two directions; on the one hand, these other terms can be used to make the
psychiatric hospital is generally associated with negative attributes, while a somatic hospital also pro- structure invisible to society. This act worsens the stigmatisation, since it conveys the impression
duces positive experiences, such as birth of new life. of self-accusation and shame. On the other hand, the term might be used for a structure where the
For those who know neither (ex-) patients nor staff, the building in its physical appearance needs to stand aim is to treat the client as a person rather than a patient. Schott and Tölle state that: «Traditionally
in as the only reliable representation of the psychiatric treatment apparatus. 47 Movies, especially, often and in the literal sense the word patient means: suffering, being passive. The modern psychiatry in contrast, wants
transmit an exaggerated image of the clinics’ conditions. Filmmakers like to use old prejudices and as much activity as possible from the patient: he should help himself and his fellow patients as far as possible. » 51
describe psychiatric institutions as prison-like complexes with wide white corridors where patients It could thus be in this line of thought that the facility’s management decided to camouflage the
are detained rather than healed. Even if the practices have evolved, there is still the image of exclu- structure and to melt it into the urban pattern. 52
sion and imprisonment reflected by the walls, behind which we don’t really know what happens. As we previously mentioned, the institution’s position on the handling of the mentally ill is also
Architecture is thus an important mediator, which transmits the proper and current conditions of transmitted toward the patients and the employees on the structure’s inside. To underline the hori-
psychiatric institutions to society. zontality of the patient-caregiver relationship, the administration at the day-care centre Adamant
The decision to no longer build psychiatric clinics outside of urbanised areas, but rather in the cen- have consciously decided to renounce the use of a break room reserved exclusively for the staff
tre of society, constitutes an important step in reducing the stigmatisation. At the same time this members. As we will discuss in more detail in chapter four, the institution’s goal is to create casual
decision produces new risks, since patients are sometimes exposed to staring gazes. This constant interactions. It was thus the responsible persons’ decision that the caregivers and the patients use
balancing act between the individual and society illustrates the institution’s bilateral position, and the same coffee machine and the same microwave; their coffee and food is the same. Furthermore,
is by far not the only one. Should the clinic transmit a hotel-like atmosphere where patients feel at home, their observations have shown that if an exclusive break room exists, the team members use it a lot
or should it rather have a hospital-like atmosphere where the patients realise that they are in a clinic, 48 and more than necessary. 53 There are thus many details, like the example just mentioned, the existence
thus in a state of acute crisis? Should contact with society be actively encouraged, or should the of isolation rooms, or whether the patient can lock his room, which illustrate the institution’s posi-
architecture provide places where the patient can retreat, where he feels protected? And in the tion toward the inside.
same logic, there is also the question of whether psychiatric structures should exist in an ostenta- We believe that architecture can convey the natural existence of psychiatric structures within our
tious way, or on the contrary, blend in with their environment and be as nondescript as possible. A society by considering the environment and seeking a dialog with the local population. Architecture
façade that expresses the psychiatric function of a building makes the institution exist socially. But should manifest in a subtle manner the presence of psychiatric facilities, while providing a positive
this same façade can also increase stigmatization, since it allows people to identify the nature of image at the same time. Spaces can tear down prejudices, where encounters between patients and
the institution from afar. 49 the population occur naturally, without being forced. It also helps when psychiatric facilities reveal
When new psychiatric facilities are being planned, it is common to find hostility among neighbours who something of themselves. A transparent institution (not only in the physical sense), transmits a dif-
justify their opposition by technical, regulatory or esthetical arguments. They consider it difficult to ferent image to the outside than a sealed off building. We think that there are only advantages to be
openly display their hostility toward a population that is, in their eyes, in trouble, dangerous or disturb- found if the structure offers activities and services open both to the public and to the patients.
ing. The architecture is thus a pretext for people’s fears of the patients, and the architect finds himself
caught between a client who needs the structure and the local population, who are sceptical about the
psychiatric facility. History has shown that those projects that offer an additional value to the local
population have a greater chance of gaining the approval of the community where they are built. In

50 cf. Architecture et santé mentale, p.1


46 cf. part 2.1 (on the handling of the mentally ill) 51 Cited from Geschichte der Psychiatrie, p. 502, see annexe for original
47 cf. Architecture et santé mentale, p.5 52 For more information on stigmatisation see part 2.2 (diagnosis)
48 Question asked by J. Montadon and 3.1 (architecture and the image of society)
49 cf. Architecture et santé mentale, p.5 53 According to A. Vallet, nurse in Adamant
CHAPTER 3: PSYCHIATRY & ARCHITECTURE 49
3.2 HEALING ENVIRONMENTS
In this section we would like to present the factors that can contribute to a healing environment, The important role of gardens and parks in hospitals 57
as well as those which should be avoided. The following research was construed for the healthcare
For patients, visitors or members of the staff, spending long hours in a hospital can be a stressful
sector in general, but may very well be applied outside this branch for preventive purposes. Accord-
experience. Nearby access to a natural landscape or a garden can enhance people’s ability to deal
ing to the motto: «what heals the sick is also good for the healthy», and many factors relating to
with stress, and thus potentially improve health outcomes.
the construction of psychiatric care facilities are also valid for residential constructions.
As we have already seen in chapter one, greenery, sunlight and fresh air were regarded as essential
After an overview of the general principles that contribute to a healing environment, the compo-
components of the healing process during the nineteenth century. But with the asylum’s loss of
nents specific to psychiatry will be presented.
prestige, the therapeutic value of access to nature disappeared from mental hospitals at the turn of
the twentieth century, and some years later also from general hospitals. Air conditioning replaced
What is a healing environment?
natural ventilation, outdoor terraces and balconies disappeared, nature succumbed to cars and
«Design is so compli- According to Jain Mallkin in The Architecture of Hospitals, 54 the term «healing environment» describes parking lots, and indoor settings designed for efficiency were often institutional and stressful for
cated that it would be a physical setting and organizational culture that are psychologically supportive, with the overall goal of
impossible not to rely patients, visitors and staff.
heavily on intuition, re-
reducing stress in order to help patients and families cope with illness, hospitalization, and sometimes, loss.
Significant research in the 1980’s and 1990’s helped to support the belief that views of or time in
gardless of the number But what should this setting look like? We found in many books descriptions and recommendations nature have a positive influence on health outcomes. It was shown that gardens were important
of scientific studies that on how to create such settings, but they were often very vague. Since it is difficult to put into
are brought to the table.
because they represented, in many respects, a complete contrast to the experience of being inside
words what a healing atmosphere should look and feel like, statements on such environments often a hospital: domestic versus institutional scale; natural versus man-made; rich, sensory experience
Good healthcare design
is equally dependent on seem dull, leading the reader to think that those recommendations are simply part of common versus limited sensory detail; varied, organic shaped versus predominance of straight lines; places
art and science. […] The sense. to be alone versus few places offering privacy; fresh air versus controlled air.
most successful design Despite the sometimes vague recommendations, some scientific approaches, like evidence-based
will be a marriage of In the last ten to twenty years, efforts have been made to reintegrate greenery and nature into
craft and research.» 1 design (EBD), do exist to analyse healing environments. EBD is a field of study that emphasizes the healthcare buildings, but too often these good intentions never see their day (or only in an atro-
importance of using credible data in order to influence the design process. The approach has become popular phied way), due to tight budgets.
in healthcare architecture in an effort to improve the patients’ and staff’s well-being.55
The above mentioned positive effects are even greater if patients, staff and visitors do not only
According to EBD 56 several environmental measures allow a better patients and staff outcome. have a view and access to small green patches, but rather if they can profit from veritable parks and
While for the patients, it is important to reduce pain and depression, the reduction of stress is gardens. They provide a setting where physical, horticultural, and other therapies can be conducted.
important for all engaged parties: staff, patient and family. Scientific studies have shown that the Their setup also offers a needed retreat from the stress of work for the staff. The green creates a
exposure to high levels of daylight and to nature can significantly alleviate pain and depression. relaxed setting for patient-visitor interaction away from the hospital interior.
Other researchers suggest that real or simulated views of nature can produce restoration from psy-
chological stress in a short amount of time. Stress is also clearly reduced when a setup is provided
that allows for good sleep and a low noise level. This can be achieved through single bedrooms and
buildings with high acoustic performances. Single bedrooms are not simply more comfortable for
the patients, but they are also perceived to be less stressful for both family and staff members than
the ones containing several beds.
It is interesting to note that having carpets instead of vinyl for floors in patient rooms seem to
increase the average length of stay.
1 Kirk Hamilton, Associate pro-
fessor of architecture and fellow
of the center for health systems
& design at texas A&M University

54 The Architecture of Hospitals, p.265-266


55 Definition from Wikipedia, Evidence Based Design
56 The Architecture of Hospitals, p.258-289 57 The Architecture of Hosptials, p. 314-329
CHAPTER 3: PSYCHIATRY & ARCHITECTURE 51
3.3 ARCHITECTURE FOR PSYCHIATRIC TREATMENT
In the preceding section we have seen what conditions are needed for a healing environment in How can we create an environment that improves feelings of security?
general. In this part we want to focus on psychiatry and its specific needs. A recommendation of the WHO on psychiatric services and architecture 63 from 1959 says that famil-
iarity with places and persons increases the patient’s sense of security. In those parts of the hospital, which
Promoting encounters are used for sleeping, meals and rest, it is important that the architectural environment conveys harmony of
«If the task of psychiatry In contrast to somatic hospitals, psychiatric facilities can only rely in a limited way on techni- proportions and colours, and that appropriate materials are used. Natural wood, wool, and leather are ac-
is to repair the lack cal support in the healing process. 58 The relationship between staff and patient goes beyond the ceptable materials in all cultures. These are materials that people like to touch as well as to see. A thick skin,
of connection between
simple accompaniment during a treatment period, 59 and interactions (mainly between therapists like the façade of the CPNVD from our case studies, can appear protective. But it can also produce
the patient and his envi-
ronment, it can lean on and patients, but also with visitors and other patients) constitute an important part of the available fear and be perceived as too repellent and too institutional.
architecture and consider «healing tools». The mentally ill, especially people suffering from depression and similar psychoses, Particular care must be taken to help the patient orientate in time and space. 64 A simple building layout
it as an active partner often retreat and encapsulate themselves in their shell. It is thus important to bring those people with obvious travel paths and clear signage, so that visitors and patients do not need to ask for help,
that can provide a posi-
into contact with others. support the feeling of security. Openings and access to plants that change with the seasons, as well
tive image of psychiatry
and of its presence in the In a regular hospital, the patient lays down during his recovery, generally passive in his bed. Encoun- as the availability of clocks, provide decoration and information as part of the daily activities, and
world.»1 ters with members of the staff do not have the same importance as in psychiatric facilities. On the allow for orientation in time.
contrary, in order to be as efficient as possible, the circulation setup in a general hospital focuses on
preventing encounters. 60 The biggest difference between a general hospital and a psychiatric facil- Protecting the patient from himself
ity can therefore be found in the quality of the spaces that allow interactions between the involved The security issue in psychiatric facilities is very important and often contradictory to other needs Daniel, patient: «When
parties. Let’s take one of our case studies, the acute day care clinic in Zürich, as an example: unlike of the patient.65 Some important questions to consider include: you are depressed, it
that building, treatment rooms should not feature a long and narrow corridor without daylight, and may be dangerous on a
How to respect the privacy of a patient in his room if it is necessary to keep an eye on him? boat. In the evening, in
with the only function to allow users to get from point A to point B. It should instead be a place to
winter, you can get rid
hang out, where informal encounters are possible. How to allow him to communicate with the exterior, to benefit from the city although the win-
of yourself in the water.
B. Laudat 61 suggests, that a new handling for the management of square meters ought to be invented to dow has to be locked? This is easier than jump-
assign surfaces more wisely. This means that spaces which are not linked to specific functions, and ing in front of a car,
Those questions show how difficult it often is in psychiatry to give a clear answer. In the end, each right?»1
that are usually called hallways or circulation areas, should be given more importance, since all those hospital management must decide which of the factors are more important to them than others.
spaces are essential for the practice of psychiatry. We will see in chapter four more precisely how the high demands on patients’ safety in the psychiat-
ric clinic in Yverdon-les-Bains (CPNVD) necessitate that many doors and windows cannot be opened
The feeling of security in a psychiatric clinic without a key. The clinic La Métairie on the other hand, has put the focus on other factors, and can
Due to the patients’ situation of acute crisis and the new and unknown environment of a psychiatric in return not offer the same security measurements as the CPNVD.
hospital, the feeling of security is often not present. But this feeling of safety and well-being is the In intermediate structures security is still an issue, but to a lesser extent than stationary clinics.
first prerequisite for the re-establishment of the patient’s normal relations with his environment. 62 Since the patient visits the intermediate structure independently, one can assume that he does not
Insecurity engenders anxiety, which is the cause of much disturbed behaviour. harbour immediate suicidal thoughts. In the day care hospital Adamant for example, a workshop
was organised before boarding the barge to discuss what it means for the patients and the staff
members to visit, respectively to work on the water.

1 Cited in Architecture et Sante 1 Cited from the article: En


Mentale, p.5, plein Paris, l’hôpital du vogue à
see annexe for original l’âme, see annexe for original
58 L’architecture au service du soin, p.1
59 cf, Mener un projet architectural en psyschiatrie, p 10
60 cf, Architecture et psychiatrie, p.41 63 WHO, Psychiatric services and architecture, p.26
61 Cited from Architecture et santé mentale, p.4 64 cf. WBDG
62 cf, Architecture et psychiatrie, p.57 65 cf. Architecture et psychiatrie, p .61
CHAPTER 3: PSYCHIATRY & ARCHITECTURE 53
Privacy in psychiatric clinics Flexibility
In stationary clinics, privacy is an important issue in order to keep a patient’s dignity, since he lives Psychiatric facilities and treatment ideologies are subject to quick and frequent changes. Practices «We must remain hum-
in the hospital and spends every minute of his days and nights in it. He should have as much visual have evolved considerably in the last decades, and the options for patients have to be adapted ble, it is the patients
who will use and define
and acoustical privacy as possible, and he should also be in control of it.66 This can be achieved constantly. 70 Therapy rooms, in particular, have to be built in a flexible and multi-purpose way. This
the space in the end.» 1
through single bedrooms, with the possibility to close the door when desired, or by offering several allows not only for different activities in the same spaces, but it also prevents unnecessarily quick
types of common spaces. It is also important to create spaces where private family meetings can obsolescence. The clinic La Métairie is a good example: the institution from the middle of the nine-
take place, while assuring a high level of acoustic isolation. But as discussed before, the need for teenth century is a listed building and changes are almost not possible. We will see in the follow-
privacy often contradicts others essential needs, such as supervision and intensive care, and makes ing chapter how the management is aware of the organisational problems linked to the outdated
this matter another delicate tightrope walk. layout, but has very limited options regarding architectural modifications.
In intermediate structures, privacy is much less an issue since patients have the possibility to return
to where they live. Patients that frequent intermediate structures are usually in a different treat-
3.4 CONCLUSION
ment phase than the ones in stationary clinics. The intermediate structures consequently devote a
lot of their efforts to encouraging interaction and the re-socialisation. 67 One can easily find a variety of advice concerning the planning of psychiatric buildings, and when
one suggestion is isolated from another, they all seem very reasonable. Problems arise when one has
Promoting choices/patient’s sense of competence to make compromises between all of these recommendations. What is in this case more important?
Due to the circumstances, an admission into a psychiatric clinic is never easy. Every person has the What will be impossible to discount?
need, to a certain extend, to organise his everyday life himself. Even though some of the patients For some issues such as the part on promoting choices, we were not at all aware of its importance.
are relieved that they can delegate the responsibility, personal freedom is severely limited in station- In others, like patient’s privacy, we had an idea of the theme, but were surprised by the far-reaching
ary clinics. Adults, who are used to having their lives under control, and to being autonomous, come architectural consequences. Certain points did not give us truly new insights. The section on the
into a system in which every detail of their daily routine is prescribed; patients become completely important role of gardens and parks is not only important to us in relation to society. In our opinion,
dependent. In regards to total institutions, Erving Goffman notes that: parks and gardens are essential to the environment of mental hospitals, and are too frequently left
out. For this reason we decided to elaborate on that topic to a certain extent.
«Total institutions disrupt or defile precisely those actions that in civil society have
the role of attesting to the actor and those in his presence that he has some command The conversation with the architect of the Adamant, Mr Ronzatti revealed that he under no circum-
over his world – that he is a person with «adult» self-determination, autonomy, and stances wanted to design a project with specific intentions regarding the type of institution. He
freedom of action. A failure to retain this kind of adult executive competency, or at believes that the spaces, if they are designed specifically for the treatment of psychiatric problems,
least the symbols of it, can produce in the inmate the terror of feeling radically de- are regularly overloaded with and compromised by intentions.
moted in the age-grading system.» 68 We think it is important for architects to know all the above described factors. But it seems to us
It is thus very important to provide each patient with the opportunity to control his immediate even more important that architects design real spaces. In this respect, we agree with Ronzatti’s
environment as much as possible. This may include: lighting level, type of music, seating options, statement. Too often an unreal atmosphere reigns in psychiatric facilities, too often psychiatrists
and also the possibility to have access to kitchen facilities, where snacks or meals can be prepared and architects want to design a building that has a soothing, calming and relaxing effect, and too
by the patient. A patient’s sense of competence is encouraged, when spaces are easy to find and to use often the result is one that we perveive as strange and unnatural in its whole.
without asking for help.69

1 J. Oury on the role of


the architect, reproduced by
J. Montadon

66 cf. Pratiques de soins en psychiatrie et réflexions sur les éléments du programme architectural, p. 7–9
67 cf. WHO, Psychiatric services and architecture, p. 24
68 Asylums, p. 43
69 Cited from WBDG 70 Architecture et Psychiatrie, p. 61
CHAPTER 3: PSYCHIATRY & ARCHITECTURE 55
CHAPTER 4
Criteria for selection of case studies CASE STUDIES
geographic location building
As we have seen in the theoretical part, there are large differenc-
in the city centre on periphery of in rural area recently built old, adapted to not built for es in psychiatric institutions. The structures’ ranges in coverage
the city nowadays standards current purpose
of the healing stages, as well as their philosophies in translating
their missions, vary greatly. Few deny that an institution cannot
cover the full range of the healing process. But where should
the cuts be made, and how can the different stages be distin-
guished? What are the psychiatric facilities’ needs and how are
CPNVD La Métairie KSPAP Adamant they transposed? What kind of relationship is maintained with
in Yverdon-les-Bains in Nyon in Zürich in Paris
society? These are the questions we want to treat in our case
study from an architectural perspective, to obtain the broadest
possible overview.
We decided to look at four psychiatric facilities: two stationary
psychiatric clinics and two psychiatric day-care clinics. These
Ambulatory (1h) Day-care hospital (8h) Clinic (24h) private public
four institutions vary greatly in their missions, the implementa-
tion of their visions, the degree of integration into society, and in
type private/ public
their construction year. This diversity makes a comparison par-
ticularly interesting.
The Centre de Psychiatrie du Nord Vaudois (CPNVD) in Yver-
don-les-Bains was inaugurated in 2005. It is one of the first sta-
Coverage by type of treatment facility tionary psychiatric clinics in Switzerland that seeks a strong inte-
gration in the urban structure of a city.
acute crisis rehabilitation reintegration prevention
La Métairie, a private stationary clinic in Nyon was opened in
CPNVD (hospital) 1860 and is today the last remaining psychiatric clinic in the
french spoken part of Switzerland.
la Métairie (hospital)
Die Klinik für Soziale Psychiatrie und Allgemeinpsychiatrie
ZH West (KSPAP) lays in the centre of Zürich. It consists of an
KSPAP (crisis intervention hospital)
acute unit, a crisis intervention unit and a rehabilitation unit that
KSPAP (acute day-care hospital) are autonomous but share the same therapy rooms to profit from
KSPAP (rehabilitation day-care hospital) synergies. The institution is located in a former office building.
stationary clinic
Adamant, the day-hospital, is located on a barge on the river
Adamant (day-care centre) Seine in the heart of Paris. It is part of the big psychiatric hospital
intermediate structure
Esquirol and opened its doors in this new location in July 2010.
Adamant (therapeutic club) ambulatory

16 Criteria for selection of case study


17 Coverage by type of treatment facility
CHAPTER 4: CASE STUDIES 57
4.1 GENERAL INFROMATION

CPNVD
Offer
Stationary hospital and ambulatory

Philosophy
Let the patient feel that he is in a hospital, where he gets professional
treatment, and which he has to leave as soon as his condition allows him to.
Systemic approach: emphasises on integration of patient’s environment in therapy

Technical data
Construction: 2003
Admission hours: stationary clinic 7/7 days – 24/24h, ambulatory 5/7 days – 8/24h
Floor surface: approx. 7200 m2
Capacity: 56 beds (3x14 beds adult psychiatry, 14 beds geriatric psychiatry)
Average length of stay: 17 days

More
Units are not separated by disorders, except geriatric unit
Patients are under occupied during the day. Many linger around,
watch TV and are bored.

18 CPNVD, overview of location


19 CPNVD, siteplan and access
CHAPTER 4: CASE STUDIES 59
La Métairie
Offer
Private stationary clinic for private and semi-private insured patients
Ambulatory, covered by basic health assurance

Philosophy
Providing psychiatric care with high hotelier standard
Emphasises on the patient’s autonomy

Technical data
Construction: 1860, (listed building)
Admission hours: stationary clinic 7/7 days – 24/24h
ambulatory 5/7 days – 8/24h
Floor surface: approx. 3000 m2 (only main building)
Capacity: 35 beds in 2 units (only main building)
Average length of stay: 28 days (varies strongly: one patient is there since 30 years)

More:
This psychiatric clinic is not well accessible by means of public transport but since
its clients are rather wealthy, they arrive usually by car or taxi.
Units are not separated by psychosis (except addiction disorders)

20 La Métairie, overview of location


21 La Métairie, siteplan and access
CHAPTER 4: CASE STUDIES 61
KSPAP
Offer
Provides three units for three different states of health: crisis intervention, acute
day-care clinic and rehabilitation clinic

Philosophy
To provide services for as many as possible, the patient comes only according to a previ-
ously defined plan of therapeutic activities
The patient should not hang out in the centre before or after the therapeutic activities

Technical data
In current premises since: 1983
Floor surface: approx. 2500 m2
Admission hours: crisis intervention 7/7 days 24/24h, acute day-care clinic 7/7 days
13/24h on working days, 4.5/24h on weekend
Clinic for rehabilitation: 5/7 days 8/24h
Length of stay by unit: 6 days in crisis intervention, 3 – 9 months in acute day-care
Clinic or/and rehabilitation clinic

More
The institution works only with patients that come voluntary and collaborate
New concept of day-care hospital that provides also a small number of beds for a
stay of maximum six nights. This can be an alternative to stationary care in some
cases and provides a continuous treatment.

22 KSPAP, overview of location


23 KSPAP, siteplan and access
CHAPTER 4: CASE STUDIES 63
Adamant
Offer
Combination of day-care centre and therapeutic club

Philosophy
Provide informal therapy in a comfortable environment
Open door policy
Emphasize on horizontal relation between care-team and visitor in the therapeutic club

Technical data
Running since: July 2010
Floor surface: 600m2

T
Admission hours: 5/7 days – 8/24h
Average length of stay: 2 weeks – 15 years
Capacity: 120 persons per day

More
Bar is managed by therapeutic club.
Belongs to Hôpital Esquirol of Paris. Employees work in several facilities on different days to pro-
mote continuous care by same staff and exchange knowledge.

24 Adamant, overview of location


25 Adamant, siteplan and access
CHAPTER 4: CASE STUDIES 65
4.2 RELATION TO SOCIETY / EXPRESSION OF BUILDING
The physical presence of a psychiatric institution can substantially shape its image in the population
and make an important contribution to combat stigmatisation. The building’s appearance is also in-
dicative of the position that the psychiatric structure takes toward its users and toward society.71
In this part we want to discuss the issues, which we treated in the theoretic part of our work, by
providing concrete examples.

CPNVD
The psychiatric clinic in Yverdon is located only six hundred meters from the train station and the
city centre in a former industrial area surrounded by diverse educational institutions and some
smaller businesses.
The building finds itself in a rather difficult environment where no one would expect a psychiatric
institution. It was not an easy task to find a good architectural solution to make it blend in with
the surroundings, while at the same time claiming its specific role. It was an advantage that the
psychiatric clinic was one of the first new constructions in this area; there were no alarmed neigh-
bours raising objections.
Today, the institution integrates itself to some extent into its surrounding by means of proportions,
rhythm of the façade and alignments with the nearby industrial buildings. But at the same time, it
marks its autonomy by its strong shell of red tinted concrete and by its freestanding form.
Through its shell and rather small openings, the building expresses a protective character. The in-
stitution’s strong appearance fulfils two important roles: firstly, it shows to the public that mental
illness is part of our society and that people with mental disorders are not to be excluded from the
same. As we have seen in the previous chapters, this helps to reduce stigmatization and prejudices.
Secondly, the building’s presence communicates to the public that there is a place where they will
be looked after, should the need arise.
As a consequence of the prominent location in the emerging neighbourhood, encounters between
patients and the public have to be planned carefully. In the CPNVD, a public restaurant, where
employees from the vicinity can eat lunch or have a coffee, promotes natural encounters that
ultimately contribute to a lessoning of prejudices. The protected but still open forecourt, where
patients hang out, is also an important transmitter of the institution’s image. But encounters could
have been pushed further by a shared outdoor space that invites patients as well as the public. 72

71 See chapter 2.1.


26 – 28 CPNVD, exterior view 72 See 4.6 outdoor spaces for further information
CHAPTER 4: CASE STUDIES 67
La Métairie
In contrast to the CPNVD, the clinic la Métairie, through its remote location to the city, does
not seek connections to society. It provides the patient with a calm and protected ambience, not
through a strong shell like the CPNVD, but through its location in a big park surrounded by trees.
The clinic is 1.2 km outside of Nyon’s city centre, on the shore of lake Geneva. Direct views in from
the outside of the plot are not possible. The clinic’s strength is the peaceful and relaxing environ-
ment. Many foreigners are attracted by the discreet setup. Those clients want to get treatment in
an intimate environment without the risk of being noticed by the public. Since this place is not
primarily a centre for crisis intervention, it places emphasis on the patients’ amenities.
Patients usually do not leave the plot during their stay and do not participate in events that take
place in the clinic’s vicinity. Certain patients might perceive this as a positive characteristic of the
clinic, although it can be a disadvantage for some. The patients are isolated on the plot and little
walks to the city are not possible because of its distance.
To handle the increasing demands for ambulatory treatment in the region, the clinic developed an
ambulatory a couple of years ago. 73 In contrast to the stationary part of the clinic, local patients
with general insurance may also benefit from the large range of options. Thanks to the ambulatory,
the clinic’s therapy options more efficiently use their capacities, and the private hospital was able
to establish a presence in the local health care system.

29 – 31 La Métairie, exterior view 73 cf. 150 ans histoire de La Métairie, p. 39


CHAPTER 4: CASE STUDIES 69
KSPAP
The day-care hospital is, thanks to its central location, optimally linked to the public transporta-
tion system. Office buildings, educational institutions, a restaurant, several apartment blocks and
a former military site, which is now used by the police, surround the institution. The building was
originally conceived as an office building and a warehouse, and corresponds to the vicinity’s prevail-
ing typology. The KSPAP is thus camouflaged in a building, which reveals nothing of its function.
The institution presents itself by craftwork in the shop windows of the former retail space, which
today hosts the cafeteria. Due to the camouflage, the KSPAP misses the opportunity to convey a
more favourable image of itself to society. Instead, it hides in the disguise of a regular office es-
tablishment, or even a warehouse. As a pubic institution, the KSPAP could provide its surroundings
with an additional value. That could be a little plaza used as a meeting place or a cafeteria accessible
to the public. 74 One must note, however, that those responsible are not happy with certain issues
themselves, and would like to change things, but are unable to do so. This is an often seen problem:
a psychiatric clinic is housed where a building is available, and those in charge have to make the
best of it. Awareness should therefore be triggered in higher spheres.

32 – 34 KSPAP, exterior view 74 See 3.1 for further information


CHAPTER 4: CASE STUDIES 71
Adamant
The day-care centre Adamant lies only three hundred meters away from the big train station «Gare
de Lyon».
Due to the exceptional and isolated location on the river, many questions in relation to the envi-
ronment do not arise in the first place. Classical psychiatric related challenges, such as disagreeing
neighbours or the access’ design, do not even come up. As a houseboat, and therefore not place
bound, the design does not need to produce a specific relationship to the surroundings. Dimensions,
proportions, and materials derive rather from the naval industry. Nonetheless, the centre tells the
observer a lot about its clients. The fully glazed façade with wooden movable flaps opens to all sides
and seeks visual contact. At the same time, it remains an autonomous island in the middle of the
city. The Seine and its banks, unlike the rest of Paris, offer something special: a lot of unspoiled
space. The rooms of the Adamant have therefore a quality that other places in the capital can only
get with a lot of money: a view and clearance.
To enter the boat, visitors must leave the ground first. This step seems a little bit as if, metaphori-
cally speaking, one is leaving society. From the water a more distant view of the city is possible and
problems can be considered from another angle. The view and the air around the institution make
an important contribution to this process.

35 – 37 Adamant, exterior view


CHAPTER 4: CASE STUDIES 73
4.3 ACCESS
The clinic near the city centre, which we have praised repeatedly, makes a major contribution toward
reducing the existing stigmatization. 75 The challenge for the architect begins, however, when a new
person is admitted to the hospital. The close vicinity to the city centre turns into a risk of stigmatiza-
tion since, starting from that moment, it is not about psychiatry in general and how it is perceived
in society anymore, but rather about an individual who becomes a patient. The central location
contains the risk that the person is recognized and experiences personal stigma. 76
Admission to a psychiatric stationary hospital seldom happens on the patient’s request, and it is in any
case a very difficult situation. The first impression when entering a hospital is therefore essential, and
can influence to a large extent whether the hospital stay is experienced positively or negatively.

CPNVD
The freestanding building is situated on a plot that is accessible from three sides. There are four en-
trances: the main entrance via the forecourt, the access for emergencies which is directly reachable
from the road, the access to the ambulatory which is located on the north-western side, and the
delivery on the south-east. The employees have an additional entrance through the parking garage.
When approaching the building, the expressive character and the form are distinguishable from afar.
The main entrance’s access is not head-on; one has to go along the smaller part of the two wings. The
forecourt, which the patients and visitors use to sit outside, reveals itself at the last moment. Since
a green open area separates the clinic from the neighbouring plot, outsiders are kept at a distance.
The lateral access maintains the intimacy, and visibility is only possible over the green area.
The red-coloured concrete walls and the red floor penetrate the building’s interior and form a fluid
transition from the outside to the inside. This makes the entrance hall appear as an exterior space.
The generous glazing also allows for good visual contact between the two areas. The importance of
the green space here becomes apparent again. It prevents passers-by from approaching too close to
the entrance area. The intimacy, despite the generous glazing, is thus also preserved here.
public accessible space
In the historical overview we discussed the Ospedale degli Innocenti. 77 As back then, many different
elements are used to form the access to the CPNVD. Their common goal is, rather than separating
the clinic from the city, to form a slow transition from one to the other. They prevent a sudden
threshold, while still preserving the patients’ privacy.
Inside the building, the foyer has on either side of the main entrance double height areas. These are
equipped with sofas and allow patients and visitors to meet and interact. Located in the axis of the
entrance is a wall that separates the public part from the internal areas, and also houses the recep-
tion. The reception is therefore clearly visible, but not overly imposing. Via the foyer one can reach
the restaurant, which is open to the public.

38 – 40 CPNVD, sequence access 75 cf. part 3.1


41 CPNVD, entrance hall 76 See 2.1. for further information
42 CPNVD, site plan access 77 See 1.2
CHAPTER 4: CASE STUDIES 75
La Métairie
The building is situated on a large plot, which is fenced in by trees and bushes that block the view
of the clinic. Only after entering the plot does the building become visible.
The driveway leads frontally to the building and emphasizes its symmetrical and lord-like character
very well. Nevertheless, when approaching, only portions of the building are recognisable as the
trees filter the view. In addition, a large tree stands exactly in the axis of the entrance and hides
the view of it until the last moment.
The sophisticated privacy protection is apparent. From the clinic, one has neither a direct view
of the access road nor the entrance area. The privacy is thus optimally protected both from the
outside and the inside.
A few steps lead into the clinic’s vestibule. When arriving in this space, one has the feeling of abso-
lute freedom of movement, as different directions in the building are available. In addition, the first
thing one sees is the facing living room with a generous glazing behind which the park is identifi-
able. The institution’s philosophy becomes clear immediately upon entering: the patient should feel
as free as possible and like he is at home. No supervision is noticeable and one can leave the building
at any time, without being seen by the receptionist.
On either side of the vestibule, long corridors lead to the units. Sofas and armchairs invite one to
relax and to exchange. Only behind the vestibule is the foyer with the reception located. The recep-
tion is comparable to that of a hotel, and personal interaction is important. This space is the node
of the strictly symmetrical clinic. In the central axis, behind the foyer, the living room is located.
The carpet, the couches, the fireplace, the piano and the paintings on the wall are reminiscent of a
comfortable upper middle-class living room.

public accessible space

43 – 45 La Métairie, sequence access


46 La Métairie, siteplan access
CHAPTER 4: CASE STUDIES 77
KSPAP
The day-care hospital is located in a former office building and surrounded by dwellings, a restaurant
and tertiary education institutes.
The institution presents itself with shop windows to the street. Upon first visit, one is therefore try-
ing to enter through the door between the windows, behind which the clinic’s cafeteria is located.
This door is closed however, and only when searching further does one find a discrete entrance on
the lateral access road. Since there is no direct view from the street, the main entrance is very
discrete.
The entrance door opens into a dark room. From there one has the possibility to go via the staircase
to the upper floors, which houses the consultation and therapy rooms. Another corridor leads from
the entrance room to the cafeteria, where patients and the staff spend their breaks. The secretariat
is located between the cafeteria and the staircase, where it is hidden behind the doorframe of a
former office. It therefore has no view of the entrance.
The atmosphere of an office building, in which several companies were installed, is still very present.
There is no entrance hall, which would establish a relationship to the outside, and which would also
promote casual encounters and provide a place for an undisturbed conversation, without obstruct-
ing the passageway. The cafeteria was originally a retail space orientated toward the street. The
connection between today’s entrance area and this room was added later and produces a restless
atmosphere. Visual contact to the entrance area, which would be useful in promoting cohesiveness,
is missing.

public accessible space

47 – 50 KSPAP, sequence access


51 KSPAP, siteplan access
CHAPTER 4: CASE STUDIES 79
Adamant
In contrast to the two stationary clinics, the architects did not deliberately design the arrival. It
derives rather from the natural conditions: Adamant is a houseboat and houseboats can only be
reached via the riverbank and the landings. A common feature with the CPNVD can nevertheless be
found: On the landing a mounted bench invites people to sit down. Upon arrival, one crosses, just
as in Yverdon, an outdoor area which is used by the patients and the staff to smoke and to talk.
When passing through one of the many doors into the arrival area, a person directly faces the
administration. But unlike in the other case studies, there is no reception. Glazing with integrated
blinds separates the entrance area from the administrative part. Those arriving thus have a filtered
view of the desks and of the river Seine.
The entrance area hosts several functions. It is at the centre of the institution and leads into the
large, circular rooms at either end of the ship. Via two flights of stairs one can also reach the lower
deck, or go into the already mentioned administration. Built-in benches, tables and chairs invite
one to stay.

public accessible space

52 – 55 Adamant, sequence access


56 Adamant, siteplan access
CHAPTER 4: CASE STUDIES 81
4.4 SPATIAL ORGANISATION

common space In this part we want to show how the four establishments translate their different treatment ap-
room for therapeutic purpose proaches into the spatial structure. The analysis will help us to understand the institutions’ function-
office ality and give us an overview of their organisation.
patient room
horizontal circulation
CPNVD
vertical circulation
entrance The H-shaped building has two wings with three floors each, which are connected by a central
administration block of two floors.
The ground floor is divided into an internal and a publicly accessible area. The public part consists of
a spacious foyer, a restaurant and a conference room. A side entrance leads to the ambulatory on
the first floor. Therapy rooms, the emergency access and a technical part form the hospital’s internal
space and are also located on this level.
Psychiatrists, psychologists, social workers, and the administration have their offices on the first
floor. The four stationary units are located on floor two and three. Each unit consists of twelve
patient rooms, examination rooms and some spaces for the staff. The patient rooms are grouped
into entities of four, and every entity shares a living room. This subdivision allows for a family-like
atmosphere among the patients, despite the size of the complex.
1st floor 3rd floor
The building offers the patients a series of retreat possibilities that become gradually more public to-
ward the outside. 78 This is important because the patient arrives in a very poor health condition and
must feel strongly protected during the first phase. Because of the central location within the city
and the limited outdoor areas available to the patients, the internal common areas become even
more important for gathering and socializing. Much attention was also dedicated to ensuring that
the team members have opportunities to withdraw from the patients. A system of doors creates
a clear division of the staff and patients’ areas on the first floor. The employees of the stationary
clinics underlined several times the importance of retreat possibilities.
The presence of an administration apparatus that is inaccessible and secretive about what goes on
behind the scenes gives the clinic an institutional appearance. There is a risk that the patient feels
«administrated» and not in control of his destiny.
N

10 20m
ground floor 2nd floor

57 CPNVD, plans, spatial organisation 78 See also p. 91


CHAPTER 4: CASE STUDIES 83
common space La Métairie
room for therapeutic purpose
Originally, the clinic had only one main building. Over the course of time, three other buildings were
office
patient room
built in order to respond to the rising demands. The so-called «Villa», the first added building, houses
horizontal circulation today primarily older and long-term patients. The most recent building dates back only a couple of
vertical circulation years and includes an ambulatory, a spa and other treatment rooms.
entrance We will limit our case study to the original main building, which still forms the heart of the struc-
ture. Its plan reflects the organisation of a classical asylum as Esquirol proposed it. 79 Originally the
separation of men and women took place in either wing of the symmetrical layout. The agitated
patients were located in each of the extremities with their own closed courtyards, 80 which are only
accessible through the building. The premises listed building and adjustments are only possible to a
limited extent. The building, therefore, has barely changed from its original form but is today used
2nd floor
according to contemporary principles. The patients are no longer segregated by gender and separa-
tions are made according to diagnoses rather than degree of agitation.
All the common rooms, therapy rooms and rooms for the staff are situated on the ground floor.
The patient rooms are located on the upper floors. Originally, the second floor was reserved for the
nurses, who at the time were rather «dames de compagnie», but today patients also use this area.
From an hotelier’s point of view, the building offers an additional value through its history and the
impressive architecture, but viewed from a functional angle, it is not efficient. Due to the sym-
metrical and linear organisation, the paths are unnecessarily long and synergies within the complex
cannot be used in an optimal way. However, there are also spatial qualities, such as the corridors on
either side of the vestibule that are equipped with sofas and invite people to linger.
1st floor A particularly high level of attention is paid to the patients’ liberty. It is striking that, except for a
few offices and technical areas, the whole building is accessible to the patient.

ground floor

10 20m
N

79 cf. 1.4: 19th century – construction of the asylum


58 La Métairie, plans, spatial organisation 80 cf. 4.6 : exterior spaces
CHAPTER 4: CASE STUDIES 85
common space
room for therapeutic purpose
KSPAP
office The building has been modified only slightly for its new use, and the original functions (office and
patient room storage building) are still very present. It is not surprising that the layout focuses on the most ef-
horizontal circulation ficient distribution of rentable square meters. This means that between the spaces with specific
vertical circulation
functions, few activities can take place, and the building also appears rather closed on the inside.
entrance
All three units are located on different floors but share most of the therapy rooms which can be
found on all floors. The crisis intervention unit, where patients have the possibility to stay up to
six days in exceptional cases, is located on the ground floor. The cafeteria and the group kitchen,
which are used for cooking in a therapeutic environment, are also located on the ground floor, but
on either side of the isolated crises intervention unit. The rehabilitation unit finds its place on the
first floor. It comprises several therapy rooms that are also used by the other units. The acute hos-
pital with some examination rooms and offices is situated on the second floor. Some more therapy
rooms, which are used by all units, can be found in the basement.
A logical organisation of the functions can only partially be identified. Since the building’s struc-
ture was already there, the functions had to be placed in rooms that were suitable but sometimes
ground floor 2nd floor located far from each other. Unfavourable associations, complicated connections and unused syner-
gies had to be accepted. The separation of the community kitchen from the cafeteria by the crisis
intervention unit is just one of many compromises that were made.
Since the patient is not supposed to linger in the building before or after his consultations, little
space has been dedicated to informal encounters. The cafeteria, which is connected to the main
entrance, is the only room that is freely accessible to all patients and staff members.

basement 1st floor


10 20m N

59 KSPAP, plans, spatial organisation


CHAPTER 4: CASE STUDIES 87
common space Adamant
room for therapeutic purpose
This floating construction has an upper and a lower deck. The spacious entrance area is located on
office
horizontal circulation
the upper deck and is adjoined by a small administration area. A therapeutic club rents the rotunda
vertical circulation on the lower end of the barge. It is equipped with a bar and seating possibilities, and functions as
entrance the reception area of the day-care centre. The room in the other rotunda of the upper deck is used
for various activities. On the lower deck three more spaces serve as multi-purpose rooms and can be
closed if needed. There are also two meeting rooms, where private conversations are possible.
The construction is characterised by a high degree of flexibility. Few rooms are separated by walls,
with the exception of the administration area on the upper deck and the two meeting rooms on
the lower deck. Most spaces on the barge are used for various activities. Fixed equipment, such as
the kitchen, the bar or the few sanitary installations, limit and structure the fluid space. The upper
and lower decks distinguish themselves by different ceiling heights and different acoustic proper-
ties. On the lower deck, one can barely hear noise from outside, since the room is up to the knees
below the water level.

upper deck

lower deck
2.5 5 10m
N

60 Adamant, plans, spatial organisation


CHAPTER 4: CASE STUDIES 89
Sequence – from private to public In a day-care hospital, the patient comes, as the name already suggests, only during the day. The
ability to retreat, therefore, does not have the same importance as it does in a stationary clinic.
The visualisation of the spatial sequences from the most public to the most private spaces shows
the huge differences between the psychiatric institutions, at a glance. In Zürich, apart from the few short-term inpatient rooms, the patient only attends the facilities for
a clearly defined program and a clearly defined amount of time, and always stays in the same room.
In the CPNVD the ramifications and the gradual transitions stand out most. In contrast to La Mé-
This explains the high density of therapy rooms in comparison to freely usable common spaces. On
tairie, there is more happening in the private part. The floor with offices in between the patient
the graphic we can also see that the therapy rooms are scattered and that the connections are
rooms and the exterior space acts as a buffer zone and strengthens the feeling of retreat in the
organised in an awkward way.
stationary units.
The graphic of Adamant shows the very simple structure, which is due to its size and its open or-
The diagram of La Métairie shows that the transition from the areas that are the most private to
ganisation. Everything is close and it is easy to keep the overview. The high number of common
those that are the most public happens more abruptly. The layout is similar to a hotel, where the
spaces and the central organisation show that the informal social interactions receive much more
client’s room is connected to the common spaces without any intermediate steps. In comparison to
the CPVND, we have to consider the fewer patients and the building’s location in a protected park importance in Adamant than in Zürich.
that makes this more open organisation possible. A significant difference also exists in the position
and number of rooms reserved for employees, which are all directly accessible from the public area.
This increases the staff’s availability and has a positive effect on the atmosphere of a transparent
organisation. It is the patient that can retreat more than the employees, rather than vice versa.
common space
common space part of circulation area
room for therapeutic purpose
office
patient room
horizontal circulation
vertical circulation

most private

not accessible to public


accessible to public
CPNVD La Métairie KSPAP Adamant most public

61 Spatial sequences from private to public


CHAPTER 4: CASE STUDIES 91
4.5 WINDOW ANALYSIS
On this and the following pages we will take a close look at the windows of psychiatric facilities to
analyse not only their relationship to the outside, but also their position toward the clients. Unfor-
tunately, we were not able to visit the small stationary part with the patient rooms in the KSPAP in
Zürich. This made a serious analysis impossible. Adamant has no patient rooms as a day-care centre.
The two intermediate structures are therefore not discussed in the first part of the analysis.
Comparison of patient room windows
The compilation of the six different window types shows the evolution that patient rooms have
undergone. In the examples of the La Metairie, it is apparent that the original windows, dating from
1860, were designed to the last detail specifically for psychiatry. The newer replacement windows
are standard models from the catalogue. In the most recent example, the patient windows of the
CPNVD, the development leads back to a specific typology with a sophisticated system.
In the time of the earliest windows represented here (fig. 62 and 64), there were two ways to pro-
tect patients from themselves. Either the openings were designed to be too small to jump out of,
or a metal grill on the outside was installed. Although the glazed surface is in both cases relatively
large, the view outside is nevertheless very limited. The oldest example stands out due to the strong
presence of subdividing glazing bars that make the windows less transparent. It conveys, just like
the grid in fig. 64, a feeling of confinement.
For the newer standard windows (fig. 63 and 65), no special considerations about the demands on
psychiatric windows are visible. We suspect that the security precautions decreased with the rise
in drug treatments, and that the approximation to a hotel room and the feeling of liberty became
more important. The latest window type (fig. 67) shows again a sophisticated security system, with-
out giving the patient the feeling of imprisonment. The two functions of a window, ventilation and
view, are separated.
The analysis clearly shows how big the impact of the different parts of an opening (frame, glazing bars,
dimensions, and materials) is. They can transmit any feeling between «locked up» and «liberty«.

62 La Métairie, original (ca. 1860) 64 La Métairie, original (ca. 1860) 66 La Métairie, replacement (ca. 1986)
63 La Métairie, replacement (ca. 2006) 65 La Métairie, replacement (ca. 2006) 67 CPNVD, original (2004)
CHAPTER 4: CASE STUDIES 93
Patient room
The opening in the CPNVD is more than a simple window. It is the connection to «the world out
there». This feeling is reinforced by the fact that the golden window frames are the only elements
that are visible on the red façade, as well as in the white room. 81 In contrast to the clinic la Mé-
tairie, it is the separation between the inner and outer space, and at the same time, the threshold
between the hospital world and the outside. The opening is relatively small, since the patient needs
to feel protected and not displayed. Its sill has the right dimension and height to sit comfortably in
the window. Since it is aligned with the outer façade, the patient can sit very close to «the world
out there» but feels at all time the wall’s protective thickness. He is, so to speak, between the inside
and the outside.
As opposed to la Métairie, the window is not perceived as a hole in the wall, but rather as an
opening to the outside. The sill’s height and the window that reaches all the way up to the ceiling
reinforce this impression. The window is custom-built and makes, through the material’s choice,
dimension and the ventilation grill, no reference to the domestic.
It was important to the architects that each patient’s room always have two windows. The view is
not guided and the patient can always choose between different perspectives. In double rooms, the
architects didn’t want to give one bed a preferred status. Even in double rooms every patient has
his own window in the longitudinal axis of the bed. In contrast to general hospitals, there are no
«window-beds» or «corridor-beds«.
The patient room in La Métairie is similar to a hotel room, which expresses a domestic scale by the
furniture, the decoration and the standard window. As in Yverdon, a view is available through two
windows.
When the patient looks out of the window, he sees the clinic’s park. As opposed to the view from
the CPNVD, nothing in his range of vision can remind him of society «out there«. The window
therefore does not form a threshold between the hospital world and the outside world.

68 La Métairie, single room 69 CPNVD, single room 70 CPNVD, double room 81 cf. Pathfinders, p. 122
CHAPTER 4: CASE STUDIES 95
Window analysis – common spaces
The diagrams on the left clearly show that all four examples use large glazing in the common areas.
They are located on ground floor level and have, with the exception of la Métairie, contact to the
public space. The connections of inner to outer space are designed differently because the rooms
have differing requirements of intimacy.
In the CPNVD, the cafeteria and the conference room seek, by their function, the strongest rela-
tionship to the outside. The green area provides the necessary privacy without restricting the view.
In La Métairie, «outdoors» is still part of the clinic. The question of the window’s size and position
in the privacy context does not arise here. The openings should instead provide a smooth transition
to the protected outdoor area and allow views to the greenery.
The KSPAP presents itself by a street facing the shop window. The cafeteria that is located just
behind it is not publicly accessible and maintains an atmosphere protected from unwanted views.
Unfortunately, the view to the outside is not filtered but blocked by a partition wall. The interior
consequently has no possibility of establishing any kind of connection to the exterior.
In Adamant, the distance to the city, as well as the wooden shutters, make a uniformly glazed
façade possible. When the day-care centre is closed, the shutters act as a protective skin. During
opening hours they will be flipped up to let light and air into the rooms, and to at the same time
filter the gazes. Thanks to the shutters, people can know from afar if the day-care centre is open
and ready to welcome the users.

private buffer zone public

71 CPNVD, exterior view 75 CPNVD, relation interior – exterior


72 La Métairie, exterior view 76 La Métairie, relation interior – exterior
73 KSAP, exterior view 77 KSPAP, relation interior – exterior
74 Adamant, exterior view 78 Adamant, relation interior – exterior
CHAPTER 4: CASE STUDIES 97
4.6 OUTDOOR SPACES
We reported extensively on the positive qualities of outdoor spaces in the third chapter. 82 If they
manage to offer an additional value to everyone, they can positively influence the clinic’s reputa-
tion within the community. The outdoor spaces affect patients and employees in a favourable way,
since it offers them recreational and meeting places.

Publicly accessible outdoor spaces


Although publicly accessible outdoor spaces are open to everybody, they belong clearly to the psy-
chiatric facility. Through this affiliation, the patient gets the feeling that this place «belongs« to him,
and other users are perceived as guests. This encourages not only the patient’s sense of security, but
also fosters – in the ideal case – encounters between patients and the community.
CPNVD: While the north-facing facades are reserved for accesses, the forecourt and the open
spaces on the south-eastern and south-western side of the clinic form the publicly accessible out-
door spaces. The forecourt works well in its role as a place of arrival and as a protected abode for the
patients. The south-facing open space is protected from the traffic and would have the opportunity
to be used. Unfortunately, its potential is not realized. The green space between the clinic and
professional school acts, in reality, as a «restricted area» between the two worlds. We were able to
observe how patients and students sat only on either rim of this zone. This observation convinced
us that there is a demand for using this open space. But trees, which would provide shade, and
other furniture that would make the space usable, are lacking. In our opinion this place has the
ideal conditions to bring the patients in contact with society. Since the students frequent the pro-
fessional school for a longer time period, they get used to the presence of the patients. Fright and
staring might give way to a naturalness and form the basis for casual encounters.
From a patient’s point of view, the gradual transition from private to public spaces works well in
the clinic’s interior. 83 But this same system is not used rigorously enough in the outdoor areas. A
gradation of outdoor spaces is missing and patients, who are not able to leave the clinic’s grounds
for walks, have limited outdoor spaces to choose from.
La Métairie: A seven hectares large park with a variety of different greenery surrounds the private
clinic. On the edge of the plot a sophisticated planting system protects the hospital from views in
three layers. Bushes, medium-sized trees and long-stemmed trees, like for example black pines, form
a green border. The park contributes a lot to the hospital’s peaceful environment and offers all the
advantages that we described in detail in «the important role of gardens and parks». 84

82 See 3.X. for further information


79 CPNVD, view public accessible open space 81 La Métairie, view public accessible open space 83 cf. 4.4.
80 CPNVD, plan public accessible open space 82 La Métairie, plan public accessible open space 84 See 3.X. for further information
CHAPTER 4: CASE STUDIES 99
KSPAP: Zürich’s day car clinic has no publicly accessible outdoor area. The access road leading to
the main entrance and to the delivery platform could nevertheless be seen as such, since people
often smoke in this quiet side street. But the spot does not belong to the clinic and no equipment,
inviting people to stay there, is installed.
Adamant: The outdoor space in the day care centre is limited to a few square meters. If the
weather is nice, the users linger on the gangways, which are equipped for this purpose with large
benches. Due to the periodic floods and the resulting evacuation procedures, the city keeps the
river’s banks free of infrastructure. The hospital management nevertheless had the option to rent a
small open area just in front of the Adamant. There are currently a few sparse trees and a few chairs.
The administration is considering purchasing more furniture so that the open area can be used dur-
ing the summer for activities. During their lunch breaks, employees of the nearby office buildings
use the promenade for jogging, picnicking or a stroll. If the day clinic carried out activities on the
bank, a zone of natural encounters between the employees and the clinic users could emerge.

83 KSPAP, view, public accessible open space 85 Adamant, view, public accessible open space
84 KSPAP, plan, public accessible open space 86 Adamant, plan, public accessible open space
CHAPTER 4: CASE STUDIES 101
Protected Outdoor Spaces
We named those spots in the fresh air, which are only available to users of the institution, and
where they are protected from curious eyes, «protected outdoor spaces». In this framework pa-
tients can explore the soothing effects of nature without being able to harm themselves or to run
away in a confused state.
As mentioned before, one of the main goals of psychiatric treatment is to lead patients back into
society. Many people retreat after a collapse and every step towards reintegration needs to be
relearnt. The protected outdoor spaces are an important feature, since they allow the patient to
perceive and to observe the outside world in a safe setting. «The world outside» consists not only of
social contacts and role distributions, but also of the weather conditions, smells, sounds and more,
all of which affect our psyche. To us, the protected outdoor spaces are a stopover in the therapy
process, where the patient, alone or in groups, consciously or unconsciously, perceives all those
external factors. One can imagine, for example, a group therapy or an art therapy taking place on
the rooftop terrace in the fresh air. The aim is to get the patient out of the interior’s protective
and insulating atmosphere.
CPNVD: The roof terrace on the second floor forms the clinic’s protected outdoor space. Theoreti-
cally both adjacent units have an entrance, but in the hospital’s daily life only the geriatric have
access. 85 The place is either designed for patients who are in an immediate crisis and are thus not
able to leave the building, or for confused patients who cannot find their way around (especially pa-
tients suffering from dementia). Their states do not permit leaving the building. Other patients do
not want to go in the forecourt for fresh air, but prefer the more sheltered atmosphere of the roof
terrace. The safety precautions are high enough that patients can go outside without supervision.
In our opinion, too few patients can benefit from the terrace. Patients whose conditions are stable
enough should have access even if their unit is not directly linked to the terrace. To us, this outer
space is aggressive and not very comforting. This is due to the red colour that might be too present,
but also to the bare surfaces and the hard lines. In addition, one feels observed due to the many
windows. We regret that there are not more plants or flowerbeds available. They could contrast
with the red colour and the patients would have, although limited, access to nature.
La Métairie: The two lateral courtyards go back to the days when patients were separated accord-
ing to their degree of agitation. 86 The two courtyards are located in the longitudinal axis to each
side of the main building. They are only accessible from the building, and a sophisticated natural
barrier of a fence, a ditch, and bushes on either side separates them from the park. Available seating
and table tennis suggest that this place is used for smoking and recreational activities. The patient
is under the open sky and still protected. A few steps and a glazed terrace join the interior and the
courtyard. The location thereby attains a character similar to a villa’s garden and seems very pleas-
ant, even though it is completely closed.

87 CPNVD, view, private open space 89 La Métairie, view, private open space 85 According to Doctor M. Grandgirard
88 La Métairie, plan, private open space 90 La Métairie, plan, private open space 86 See 1.4 for more information
CHAPTER 4: CASE STUDIES 103
KSPAP: The space between the L-shaped day hospital and the neighbouring building is a patio of
sorts, and is only used during good weather. The cafeteria that has a direct door is the most fre-
quently used point of access, but it is also accessible from the staircase. The space is relatively quiet
but has a slightly threatening effect, since it is clamped between the two high buildings. Visual
contact to and from the road is reduced, thanks to an opaque, shoulder-high gate.
Adamant: The day centre Adamant does not have a true protected outdoor space. The long bal-
conies on the riverside are the only places one could assign these qualities to. On the upper deck,
only the administrational part gives access to the balcony, and therefore it is exclusively used by
the team to smoke. On the lower deck’s balcony, a staff member must always accompany the
patients for safety reasons. We regret that the centre does not have a more generous place in the
open air, where safety concerns are no issue. Many houseboats have roof terraces where potted
plants protect from others’ gazes. We wonder whether this could have been an ideal option for a
protected outdoor space for the day care centre. On the other hand, the whole building is, for a
large part, glazed, and in summer the majority of the windows are open. As a result, the demand
for a protected outdoor space may not be as great as elsewhere.

Conclusion Outdoor spaces


Acute care hospitals have a legitimate claim for protected outdoor spaces, in order to allow troubled
patients access to fresh air in a protected environment. In intermediate structures an outdoor area
is just as beneficial, but it cannot be considered an absolute necessity. As we have seen, there are
various ways to design such a place.
Too little attention is generally paid to the quality of external spaces, and their potential is therefore
not exploited. This may (as in the case of Adamant) already occur in the design phase, or it may be
neglected in the organisation and management of the institution (as in the case of the CPNVD).
Little effort would be needed to make these areas more attractive. Plants have a big impact on the
atmosphere, but they need maintenance, and the question of who will take responsibility arises. Nev-
ertheless, it seems beneficial to include plants in therapy, and the maintenance could be part of it.

91 KSPAP, view, private open space 93 Adaman, view, private open space
92 KSPAP, plan, private open space 94 Adamant, plan, private open space
CHAPTER 4: CASE STUDIES 105
4.7 IMPRESSIONS OF THE INTERIOR SPACES

CPNVD, Yverdon La Métairie, Nyon

95 Patients room 98 Entrance hall 101 Corridor 104 Reception


96 Common space geriatrie 99 Corridor patients area 102 Patients room 105 Dining room
97 Cantine 100 Room for ergotherapy 103 Living room on the extremity of the building 106 Central common room
CHAPTER 4: CASE STUDIES 107
KSPAP, Zürich Adamant, Paris

107 Office/private discussion room 110 Waiting area 113 Library on lower deck 116 Bar social club
108 Tabletennis in basement 111 Music therapy/ pleasure therapy in basement 114 Multipurpouse room with stored tools for therapeutic activities 117 Social club
109 Corridor 112 Art therapy room on 1st floor 115 Group discussion 118 Entrance hall
CHAPTER 4: CASE STUDIES 109
4.8 CONCLUSION

CPNVD KSPAP
The psychiatric clinic in Yverdon-les-Bains was built only a few years ago in close collaboration with The KSPAP in Zürich addresses patients already in a state of crisis and covers with its care a large
the responsible specialists. The architects succeeded in translating the exact ideas of the leading part of the healing process. Due to the additional supply of short-term beds, it is also a real alterna-
medical team into a sensitive project. The building is able to convey the institution’s clear position tive to stationary treatment.
towards society and towards its users. The striking red facade and the clean, white interior underline In order to stay efficient, a conscious decision was made not to create a hangout place like in Ada-
this bilateral position. mant, where patients can come and go as they wish. Many therapeutic club-like structures exist in
We understand Mrs Montandon’s belief that a stationary clinic is not a hotel, and that the patients Zürich, but in other locations.
should be aware of their condition. In our opinion, however, the architects were in some points It is interesting to see that the institution is able to fulfil its mission despite the unfavorable ar-
too severe. We wonder whether it was really necessary for the patients’ rooms to be that bare and chitectural conditions. The centre however, can, not nearly exploit the therapeutic potential of
only sparsely furnished, or whether the roof terrace, which is characterised by hard lines and the informal encounters that happen before and after scheduled consultations.
pervading red colour, can fulfil its objective as an outdoor space. There is some doubt on whether We regret that all efforts to give the centre a more personal touch and to make it more comfortable
or not an environment that is at times perceived as uncomfortable, and that the patient wants only occurred in the individual rooms. The long corridors appear even more anonymous and give the
to leave as quickly as possible, can have a positive effect on the healing process, since the patient whole building a constricting character.
mobilises all his energies.
We like this project because of the many stages between the most private and the most public areas Adamant
that are provided to the patients, and also because so much attention was paid to the protection The atmosphere in the day-care centre corresponds much more to a cosy corner pub than to a psy-
of their privacy. chiatric setting. In this regard the dedicated medical staff and the architect succeeded in creating
an open meeting centre. In the first place, one enters a houseboat and not a psychiatric institution.
La Métairie This circumstance might help to create, seemingly without effort, an atmosphere that is in no way
After seeing the CPNVD, we also visited the private clinic La Métairie in Nyon. We were surprised reminiscent of an institution. This absence of a medical environment brings a therapeutic impact
that two hospitals, which have on first sight similar missions, can have such differing layouts. to the building.
Some reasons can be found in the larger budget of La Métairie, as well as in the higher demands of Due to the day-centre’s small size, many different therapeutic rooms had to be housed in one space.
the clients. But more importantly, when this clinic was built more than a hundred and fifty years Modifiable premises were the most obvious solution. But the architecture’s flexibility is only able to
ago, the average length of stay was a multiple of the average in today’s acute care hospitals. There- develop to its full extent, because the organisation of the staff is also very flexible.
fore, the clinic more resembles a rehabilitation hospital than an acute hospital. The average length The project, however, fascinates us mainly because the centre is able to create with simple means
of stay in La Métairie is even today longer than in the CPNVD, for example. an island in the city centre. Through the step from land to barge, one seems to leave society for an
At the beginning we were sceptical about the concept of the private hospital, where the patients instant, and receives therefore a distant view of the same.
are treated like in a first-class hotel. We recognise however, that people should be treated within
their cultural environment so that they can feel comfortable, General
We believe that the freedom and the possibility to benefit from the undisputed healing effect of We tried to break down the complex apparatus of the four case studies into their architectural com-
nature as a therapeutic tool are the advantages of this clinic. It clearly offers the possibility to ponents. We do not judge the individual institutions as good or bad. All of them show remarkable
retreat and gain peace of mind. The charm of the property comes from, among other elements, as well as less favourable solutions to complex situations.
the historically significant architecture, although the spatial organisation is no longer very efficient Each of the examples addresses a different target group, take on a different position in the handling
according to today’s standards. of patients, and has a different starting position. All these factors influence the architecture.
La Métairie makes an important contribution as a component of the broad offer of mental health The diversity of the case studies allowed us to obtain a broad overview of different approaches. We
facilities that cover all individual needs. realised that if a psychiatric facility covers a too wide range of the healing process, contradictions
may arise in dealing with patients and their environment. We particularly noticed the importance
of the structures’ flexibility and adaptability for changing ideas and needs.

CHAPTER 4: CASE STUDIES 111


CONCLUSION OF RESEARCH
Thanks to the elaboration of the theoretical part, in combination with the lieve to be a promising one. The model’s flexibility is advantageous and will
practical case studies, we obtained a broad overview of a topic about which possibly become a new trend in the mental health system.
we knew little in the beginning of the semester. The more knowledge we An architect for such building therefore does not deal with just sick or
gathered, the more our interest grew. The field of psychiatry is incredibly healthy people, but with the whole range in between. This requires not
large, and we were unable to examine all the aspects extensively in the only a high degree of flexibility in the administration and staff, but also in
given time frame. The work could still be enriched with many further top- the architecture.
ics, but it would be beyond the scope of this énoncé théorique. We tried to But this also means that a single ideal environment for the mentally ill does
find a good balance between a wide coverage and the in-depth discussion not exist. The ideal space depends rather on the patient’s stage of illness. A
of certain points. well-functioning space for the mentally ill has basically the same require-
Through the case studies we have come in contact with many interesting ments as such a room for the healthy. Just as in an ideal residence, a station-
people, and we were able to conduct detailed visits with several psychiatric ary clinic should protect from noise, offer retreat opportunities and promote
institutions. We were not able to accommodate all of the acquired informa- social interaction. Like the corner pub, an open day centre should welcome
tion in this work, but they will be of great use in the upcoming project. everybody, offer a platform for exchange and cooperation, and have quiet
People undergoing psychiatric treatment and the “healthy” members of seating corners where personal discussions can take place.
society are still in a complicated relationship. The gap between the two In addition however, the room for the mentally ill has to offer more. The
worlds is still large, and the issue of stigma still exists. It is therefore neces- organisation of a psychiatric institution, specifically its architecture, influ-
sary to work actively on integrating the two groups, and we believe that ences the patient-patient and staff-patient relationship greatly. Often these
architecture can provide an important contribution. different requirements are in conflict with each other. For example, there
To date, there are two different architectural approaches to respond to the is a tension between maintaining the patient’s privacy and the necessary
situation. On the one hand, a building can draw attention to itself and its control of their actions and activities. It is also the task of the architect to
purpose, therefore creating an awarness. On the other hand, a building can create a protection zone, in which the patient feels comfortable and is able
also be very unpretentious, integrate itself into the environment, and thus to open up, while at the same time preventing the creation of an “illusion-
show that psychiatry is just one part of society. In any case, it is important ary world”, which is so far removed from reality that the patient does not
that the architecture is designed according to the institution’s purpose and want to return to his old environment. The question also arises over to what
needs. It should not pretend to be something it is not. The two approaches degree the space should be open to the outside, in order to enable commu-
should not be forced, but sensitive, and above all, adjusted to the patient’s nication between the patient and the outside world, while still guaranteeing
condition. A space should be created in which society and psychiatry meet secure accommodation.
naturally. The balancing act between the above mentioned requirements constitutes
It has been shown that the boundaries between a person who is classified the challenge to the architectural space to be created - and therefore to us.
as healthy or ill are extremely blurred. The patient’s stage of illness is often We believe that the questions raised here are not to be answered in general,
difficult to determine and alters constantly. Due to a lack of alternatives, by a one size fits all response, but that they need to be answered individu-
too many patients are admitted to stationary hospitals. With its crisis in- ally with architectural finesse, according to each situation and considering
tervention unit, the KSPAP in Zürich succeeded in creating a new model all of its components.
that could be classified as falling between an intermediate and a stationary We are looking forward to developing a balanced and well-planned archi-
structure. The institution decided on an innovative approach that we be- tectural project for this exciting topic in the next semester.

CONCLUSION OF RESEARCH 113


CHAPTER 6
ANNEXE
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CHAPTER 6: ANNEXE 117


56 Adamant, siteplan access, based on plans by Seine Design, Paris
VISUAL MATERIAL
57 CPNVD, plans, spatial organisation, Devanthéry & Lamunière Architects, Lausanne
Visual material by the authors, unless stated otherwise. 59 KSPAP, plans, spatial organisation, based on plans by Hochbauamt Kt. ZH
60 Adamant, plans, spatial organisation, based on plans by Seine Design, Paris
1 City plan of Florence, based on historic map by Pitini
72 La Métairie, exterior view, from http://www.lametairie.ch/
2 Arcades of the Ospedale degli innocenti,
80 CPNVD, plan public accessible open space, based on plans by Devanthéry & Lamunière
http://www.flickr.com/photos/poluz/2445240745/sizes/o/in/photostream/
Architects, Lausanne
3 Schematische Josephinische Landesaufnahme Wien, 1764
81 La Métairie, view public accessible open space,
4 Lieux de folie, monuments de raison: architecture et psychiatrie en Suisse romande, 150 ans Histoire de La Métairie / Clinique La Métairie (ed.). Nyon, 2009
1830-1930 / Catherine Fussinger, Deodaat Tevaearai.
84 KSPAP, plan, public accessible open space, based on plans by Hochbauamt des Kt. ZH
Lausanne: Presses Polytechniques et Universitaires Romandes, cop. 1998
88 La Métairie, plan, private open space,
5 Lieux de folie, monuments de raison: architecture et psychiatrie en Suisse romande,
based on plans by Devanthéry & Lamunière Architects, Lausan
1830-1930 / Catherine Fussinger, Deodaat Tevaearai.
Lausanne: Presses Polytechniques et Universitaires Romandes, cop. 1998 92 KSPAP, plan, private open space, based on plans by Hochbauamt des Kt. ZH
6 Einführung in die Psychiatrie, Göthe Universität Frankfuhrt am Main 95 Patients room
7 Daten zur Versorgung psychisch kranker in der Schweiz - Arbeitsdokument 4, 98 Entrance hall, Bauwelt, n° 37, 2003
Schweizer Gesundheitsobservatorium 102 Patients room, http://www.lametairie.ch/
8 Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung 103 Living room on the extremity of the building, http://www.lametairie.ch/
und Wiederherstellung der psychischen Gesundheit der Bevölkerung in der Schweiz 105 Dining room, http://www.lametairie.ch/
9 Patientenstatistiken Psychiatrische Klink PK, 2009
10 Daten zur Versorgung psychisch kranker in der Schweiz - Arbeitsdokument 4,
Schweizer Gesundheitsobservatorium
11 Coverage by type of treatment facility
12 Fields of psychiatric services, Annual Rapport 2005, Institutions psychiatriques du canton
de Vaud
13 Average length of stay in stationary psychiatric hospital/ Number of hospitalisations,
Annual Rapport 2006, Institutions psychiatriques du canton de Vaud
14 Number of persons using psychiatric services per year, Inventar psychiatrischer
Einrichtungen in der Schweiz 2006, Schweizer Gesundheitsobservatorium
15 Movie, One flew over the cooko’s nest, Warner Bros, Entertainment, 1975
16 Criteria for selection of case study
17 Coverage by type of treatment facility
29 La Métairie, exterior view, 150 ans Histoire de La Métairie / Clinique La Métairie (ed.).
Nyon, 2009
41 CPNVD, entrance hall, Pathfinders / Devanthéry & Lamunière.
Gollion: Infolio éditions, 2005.
42 CPNVD, site plan access, based on plans by Devanthéry & Lamunière Architects, Lausanne
51 KSPAP, siteplan access, based on plans by Hochbauamt Kt. ZH

CHAPTER 6: ANNEXE 119


QUOTATIONS IN ORIGINAL LANGUAGE
CHAPTER 1
From the Renaissance to the French revolution The early 20th century – decline of the asylum
Architecture et psychiatrie , p. 17: Nouvelle histoire de la psychiatrie, p. 351:
«À Florence les hôpitaux sont construits comme des bâtiments royaux: il y a de la très bonne nourriture Paul Balvet: «L’asile d’aliénés a changé de nom, la réalité est restée.»
et boissons pour tout le monde, les valets sont très diligents, les médecins très savants, les linges et les
vêtements très propres et les lits sont peints. Dès qu’un malade est amené à l’hôpital, on le déshabille
de tous ses vêtements qui, en présence d’un notaire, sont honnêtement laissés en dépôt. On l’habille CHAPTER 2
d’un bourgeron blanc, on le met dans in beau lit peint, avec des draps de pure soie. Juste après, on Who can get mentally ill?
conduit deux médecins et plus tard les valets amènent à man-ger et à boire dans des verres propres, Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederher-
qu’ils ne touchent pas étant donné qu’ils sont servis sur un plateau. Ensuite des femmes honnêtes, stellung der psychischen Gesundheit der Bevölkerung in der Schweiz, p. 20:
toutes voilées, pendant des jours, presque inconnues, servent les pauvres et après rentrent chez elles. «Jede Generation muss in jeder Lebensphase andere psychische Herausforderungen bewältigen. In Situ-
J’ai vu à Florence avec combien de soin les hôpi-taux sont entretenus ! » ationen von kritischen Lebensereignissen und in Phasen von Lebensübergängen sind Menschen ver-
Blasius, 1989, p. 21, taken from Geschichte der Psychiatrie, p. 238: letzlicher, insbesondere wenn dazu noch erschwerte Lebensbedingungen kommen. Solche Situationen
«Im Zeitalter des Absolutismus wurden Irre, deren Zugehörigkeit zur menschlichen Gesellschaft im können zu psychischen Krisen führen, das Gleichgewicht der psychischen Gesundheit gefährden und
Mittelalter und in der Renassance trotz aller Härte des Umgangs unbestriiten war, von der Strasse und psychische Krankheiten auslösen.»
damit aus dem öffentlichen Bewusstsein verbannt […] .»
Nouvelle histoire de la psychiatrie, p. 71: The problem of stigmatization
«Leur emplacement symbolise un «no man’s land» à la fois géographique et social, placé entre le monde Geschichte der Psychiatrie, p. 502:
civilisé et le monde sauvage, à la limite entre l’organisation rassurante de la ville et l’insécurité de la «Traditionell und dem Wortsinn nach heisst Patientsein: leidend, passiv sein. Demgegenüber will die
forêt environnante.» moderne Psychiatrie möglichst viel Aktivität des Patienten: Er soll sich selbst helfen, soviel er kann,
und auch seinen Mitpatienten, soweit es möglich ist, beispielsweise in der Gruppenpsycho-therapie
The end of the 18th century – the moral treatment und in der soziotherapeutischen Gruppenarbeit.»
Nouvelle histoire de la psychiatrie, p.119:
«À la différence des bâtiments d’hôpitaux qui ne sont pour les malades que des moyens auxiliaires, les The resulting costs of mental illness
hôpitaux pour les fous font eux-mêmes fonction de remède […]. Il faut que le fou, durant le traitement, Annual Rapports 2004, Institutions psychiatriques du canton de Vaud, edited by the cantonal
ne soit point contrarié; qu’il puisse, dans les moments où il est surveillé, sortir de sa loge, parcourir la commission of psychiatric coordination, p. 4:
galerie, se rendre au promenoir, faire un exercice qui dissipe et que la nature lui commande.» «[…] ce qui concerne l’invalidité pour raisons psychiques, il est dificile d’y accéder, et peut-être encore
plus difficile d’en sortir, meme lorsqu’on se sent prêt.»
The 19th century - construction of the asylum
Architecture et Psychiatrie, p. 20. Cited there in Des maladies mentales considérées sous les rap- Treatment approaches
ports médical, hygiénique et médico-légal, J.E. Esquirol, Bruxelles, 1838: Annual Rapports 2006, Institutions psychiatriques du canton de Vaud, edited by the cantonal
«Les établissements dans lesquels les aliénés sont logés au premier, au second, au troisième étage, of- commission of psychiatric coordination, p. 9:
frent de nombreux et de graves inconvé-nients. […] il faut grillager les croisées de tous les quartiers «Forme de traitement psychologique qui utilise la relation médecin-malade pour découvrir la source
pour prévenir les évasions et les suicides ; il faut entourer de grilles les escaliers. […] Les asiles dont les des troubles, libérer le fonctionnement mental et favoriser la guérison. il existe plusieurs types de psy-
bâtiments sont construits au rez-de-chaussée présentent des avantages sans nombre. […] les galeries chothérapies; les plus connues (et reconnues en psychiatrie) sont la psycho- thérapie psy-chanalytique
peuvent rester ouvertes ; les aliénés sont moins casaniers, peuvent sortir à volonté…» (dérivée de la psychanalyse), la psychothérapie familiale systémique et la psychothérapie cognitivo-
comportementale.»

CHAPTER 6: ANNEXE 121


Intermediate structures CHAPTER 3
Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederher- Architecture and the image of psychiatry
stellung der psychischen Gesundheit der Bevölkerung in der Schweiz, p. 42: Geschichte der Psychiatrie, p. 502:
«Im Jahr 2000 (Krankenhausstatistik, 2001) sind 48 364 stationäre und 2 139 teilstationäre Hospi- «Traditionell und dem Wortsinn nach heisst Patientsein: leidend, passiv sein. Demgegenüber will die
talisationen in der Psychiatrie erfasst worden. Eine aktuelle Stichtagerhebung über die Behandlungs- moderne Psychiatrie möglichst viel Aktivität des Patienten: Er soll sich selbst helfen, soviel er kann,
situation von 1 343 PatientInnen in sieben psychiatrischen Kliniken des Kantons Zürich zeigt, dass 44 und auch seinen Mitpatienten, soweit es möglich ist.»
Prozent der PatientInnen nicht in einer Klinik behandelt werden müssten.»
What is a healing environment?
From the movie L’Adamant: l’ hôpital psychiatrique sur l’eau Citation by Henri Maldiney in Architecture et santé mentale, p.5:
«L’hôpital de jour […] permet au patient qui est stabilisé d’une crise après une hospitalisation de pou- «Un espace universel déqualifie et banalise le corps, Un espace totalitaire le met au pas et l’aliène en
voir regagner son domicile tout en bénéficiant des soins plus important qu’une consultation tout les l’assujettissant, Un espace d’accueil de la dimension du corps gratifie l’homme et lui permet d’être
semaines ou tout les mois. La plupart des patients qui fréquentent l’hôpital de jour ont été hospitalisé lui-même.»
plusieurs moins, voir des années pour certains, et pour eux la sortie de l’hôpital est un problème. Il y
a vingt ou trente ans, ces patients là, étaient condamné à rester à l’hôpital / à l’asile. Ils restaient sur
un fauteuil devant la télé fumant une cigarette. Ils ne sortaient pas, parce que leurs psychoses ne les Architecture for psychiatric treatment
permettaient pas d’accéder à la vie dans une cité […]. C’est pour ces patients là, que la structure de Architecture et santé mentale, p.5:
l’Hôpital de jour existe.» «Si la psychiatrie s’attache à réparer le défaut de lien entre le patient et son environnement, elle peut
s’apppuyer sur l’architecture, en la considérant comme un moyen qui permet, patiemment, de redonner
aux gens qui souffrent une image positive de leur corps et de leur présence au monde. Constuire pour
Ambulatory
l’homme qui souffre d’une maladie mentale constitue une magnifique preuve de reconnaissance.»
Annual Rapports 2003, Institutions psychiatriques du canton de Vaud, edited by the cantonal
commission of psychiatric coordination, p. 12:
Promoting encounters
«Ambulatoire se dit d’un traitement extra-hospitalier qui n’interromt pas les activités du malade.»
Architecture et santé mentale, p.4:
«Il y a donc une nouvelle question des metres carrés à inventer.»
Advantages and risks
Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederher-
stellung der psychischen Gesundheit der Bevölker-ung in der Schweiz, p. 8: Protecting the patient from himself
«Für PatientInnen mit schweren psychischen Krankheiten und mit sozialen Beeinträchtigungen, die En plein Paris, l’hôpital du vogue à l’âme:
heute wiederholt stationär behandelt werden, stehen nicht in ausreichendem Mass abgestimmte am- «Quand on est déprimé, c’est peut-être dangereux un bateau.» De nouveau, la peur: «A 17 heures, le soir,
bulante und teilstationäre Dienste zur Verfügung. In Folge dieses Mangels an koordinierten Angeboten en hiver, on peut se débarrasser dans l’eau. C’est plus facile que de se jeter sous une voiture, non ?»
ist eine zweckmässige, wirksame und wirtschaftliche Behandlung und Betreuung psychisch kranker
Menschen nicht immer gewährleistet.»

CHAPTER 6: ANNEXE 123


THANKS

For professional support:


Sonja Flick, head of department rehabilitation unit
of the KSPAP, Zürich
Marc Grandgirard, assisant doctor in psychiatry,
Lausanne
Dr Nicola Gervasoni, medical director of the clinic
la Métairie, Nyon
Inès Lamunière, architect of the CPNVD,
devanthéry&lamunière architectes, Lausanne
Dr Jo Montandon, head of department of the CPNVD,
Yverdon-les-Bains
Gérard Ronzatti, architect of Adamant,
Seine Design, Paris
Katiuska Stekel, responsable of the Atelier Brico-CES-
services («les ateliers») of the psychiatric university hospi-
tal CHUV, Prilly
In the day-care centre Adamant: Arnaud Vallet, nurse;
Linda De Zitter, psychologe; Lisa Prévot and many more

For editorial support:


Yara Greuter, Basel
Kim Handel, San Franscisco
Merle Zadeh, Frankfurt

For the accompaniment:


Professor Bruno Marchand
Götz Menzel
Professor Harry Gugger
4 units for 4 states of mental health

acute crisis rehabilitation reintegration prevention

KIZ (kriseninterventionszentrum)

cke
ATK

dbrü
(akut-tagesklinik)

Har
Stadion
Letzigrund

se
stras
Lang
Albisrieder-Platz Zürich HB

Central

Badene
Friedhof rstrass
Sihlfeld e

Stadtplan-4 ZPR (zentrum für psychiatrische rehabilitation)

SS (social service)

other psych. institutions


PUK institutions
site stationary clinic
intermediate structure
existing situation outpatient centre
psychiatric institutions on zürich
4 units for 4 states of mental health

efficient circulation system


proximity of collaborators

architecture of institution
care team

flow promotes encounters protecting ambiance marking presence by central position


casual encounter space transparence of the building convey positive image through physical appearance
contact points comfortable spaces transparency of the building
proximity of staff display window with patients artwork

office/commerce
housing
Quartierplan-6 protection of privacy
site clinic
flow promotes encounters controlled visual connections to exterior
casual encounter space informal encouter space for community and patients
stations
proposed densification (café, courtyard...)
100m
bus & tram lines
site patient community
public transportation buildings
patient
fountains
greenery

diversity of of
relations relations
the institution

living
commerce
health establishments
public buildings
shape of perimeter development view from east
social encounters
100m grocery store
fountains
access green area on plot
greenery
commerce on groundfloor
discus- discus-
offices sion offices offices sion offices
area area

printer printer
conference conference
offices offices offices offices
room room

research
administration
discus- discus-

functions offices sion


area
offices offices sion
area
offices

printer printer

conference offices secretariat head conference offices secretariat head


room office room office

waiting area waiting area


library consultation rooms consultation rooms library consultation rooms consultation rooms

relaxa- relaxa-
waiting waiting
consultation rooms consultation rooms tion consultation rooms consultation rooms tion
area area
area area

outpatient centre

art therapy mingling art therapy mingling


area area
gymnastic gymnastic

therapeutic yoga therapeutic yoga


kitchen pleasure cognitiv kitchen pleasure cognitiv
therapy training therapy training

ergo therapy ergo therapy


therapeutic lockers therapeutic lockers
kitchen gymnastic therapeutic activities kitchen gymnastic

mingling yoga mingling yoga


group therapy area group therapy area
ping pong lockers ping pong lockers

terrace terrace
examination examination
discussion rooms head discussion rooms head
room room
office office
head heart and contact point of heart and contact point of head
office heart zpr heart atk office heart zpr heart atk
acute daycare clinic (ATK) centre for psychiatric rehabilitation (ZPR)
staff offices group therapy staff offices staff offices group therapy staff offices

circulation flow

daycare hospital

living room patient living room patient


rooms rooms

night night
guard guard
patient patient
rooms rooms
staff staff
room therapeutic garden room therapeutic garden

head head
office office

entrance living room entrance living room

restrooms entrance restrooms entrance

mingling
café, restaurant crisis intervention centre (KIZ) mingling
café, restaurant crisis inte
offices reception area interiour public area offices reception area
centre of the clinic
entrance bar entrance bar
social service kitchen entrance social service kitchen

entrance

organisation of the building functions

views
cross-section 1:200

1
t-
en
sem
0
20
ba 1/

basement -1, 1:500

2
t-
en
sem 0
ba 1/
20
basement -2, 1:500

siteplan 1:1000 50m


ce
en
nfer
co

g
terin
ca
itiv
gn
co aining
tr

y ters
erap prin
th
art
y
erap
th
re
su
plea

tic
eu
erap n
th tche
ki

3rd floor 1:200 6th floor 1:200


e
offic

e
offic

sium
mna
gy
e
stor

/
ging
e
offic

an
ch ilets
to
m
ith
rw
ch othe
ren
m
ild

/
e
ag

ging
stor

an
ch ilets
to
w
room
t's
tien
pa
room

y
e
stor

t's

erap
tien

th
pa

ergo

ters
room

prin
e
ag

t's
stor

tien
room

pa
on
mm
co

n
ace

he
kitc
terr

tic
eu
e
offic

erap
th
e
ag
stor

room
t's
tien

y
rant erap
pa

au
rest p th en
ce
grou nfer
co
room
t's

r
tien

o
pa

flo
om
n ro

d
ussio

0
2n
room

20
disc

2nd floor 1:200 1/ 5th floor 1:200


t's
tien
pa

room

fe
ca
info
t's
tien
pa

n
ard

he
t gu

kitc
nigh

room

r
ba
t's
tien
pa
n
he
kitc
tea

om
f ro
staf

e
fic
f of
staf

ion
pt
rece
ion
inat
am
ex
y
ac
arm
ph

ad
he fice
of k
at
tion
ulta
ns
co
ice tion
xa
serv rela ne
cial zo
so
ce
offi
f
staf k
at

r
loo
df
un 0
gro 1/
20
ting
wai ea
ar

co
ns
ulta
tion
ground floor 1:200 us
sion p y
grou erap
disc th

st
logi
ho
yc
ps

ing
ad read rner
he fice co
of r
zp
fice
f of
staf r
zp

1st floor 1:200 4th floor


south-east elevation

north-east elevation

section 1:33
north-west elevation

south-west elevation
view from zypressenstrasse

perspective section

courtyard