"Design of an environmentally friendly Psychiatric Rehabilitation Clinic for drug-induced Psychosis in Vienna."
The clinical picture of psychotic states is quite extensive. The affected person perceives a wide range of delusions, persecutory mania or paranoia. Acoustic and / or optical hallucinations can occur, which affect the sense of smell, taste and touch. The environment often no longer seems to be real to those affected. The false idea that their thoughts are perceived or influenced by others can also be part of the clinical picture. “Thinking disorders often show up in the form of problems in the formal thinking process, which may appear as a lack of focus or confusion. Mood swings often accompany the psychotic symptoms. ” (Gaebel and Zielasek, no date) This way, those who are suffering from the disease gradually lose touch with reality. Furthermore, their personality drastically changes without them realizing it. The first symptoms are as followed: difficulty concentrating, disturbed thought process, insomnia, which are accompanied by a general anxiety. Later symptoms include obsessive thoughts, sudden strong interest in religion, mysticism or magic, distrust and hostility towards others, strong egocentrism, hallucinations and severe emotional changes. The causes include physical illnesses such as dementia or multiple sclerosis and the influence of medication and drugs. People suffering from preexisting mental illnesses such as schizophrenia, depression or bipolar disorder are especially affected by psychotic episodes. (Müller and Laier, 2014, pp. 17-25) One forth of psychotics are at increased risk of developing further diseases. The suicide rate lies around 10 percent and is therefore drastically increased. They are also believed to have a higher rate of addictive behavior. Often psychotics are homeless or become victims of crime. They tend to commit acts of violence more frequently. Psychoses are classified in two different categories: organic and non-organic. Organic psychoses can be triggered as a result of brain disease, brain injury or autoimmune disease, as well as due to substance abuse. They are further differentiated into acute or chronic organic psychoses. Non-organic psychoses belong to the schizophrenic form or to the affective psychoses which can occur because of a depression or bipolar disorder. Psychoses are treated with second generation antipsychotics and psychotherapy. With an early diagnosis and consistent adherence to the treatment, a positive outcome is likely. (Dieckhöfer and Gerabek, 2005, pp. 35-56)
The most known hallucinogenic drugs include LSD, mescaline and psilocybin. These can cause changes in perception, which are manifested visually, acoustically or even haptically. Hallucinogenic agents have been found in almost 150 plants, but mainly in cacti and mushrooms. (Kozar, 2010, pp. 28-30) Such substances can trigger pseudo-hallucinations, so the user is aware that the hallucination is not real, but they cannot distance themself emotionally. This differs from a real hallucination, as the person affected can no longer differentiate between what is real and what is not. The side effects include increased body temperature and blood pressure, dilated pupils and increased reflexes. The commonly occurring perceptual disturbances are primarily felt in the visual area, but are also noticeable in the auditory or haptic field. (Uchtenhagen and Ziegelgänsberger, 2000, p. 23) Many users describe a stronger, more vivid perception of colors. There is a so-called flashback phenomena, which occur months to years after the psychotic episode and are not described as delusional. These deviate from acute psychosis. However, there is a danger of getting a chronic and therefore permanent psychotic disorder. (Schmidbauer and Vom Scheidt, 2004, p. 17) The use of hallucinogenic drugs can trigger an induced psychotic disorder or a schizophrenia-like psychosis, which can last up to six months. It is widely known that drug consumption can trigger an early outbreak of schizophrenia. (Hermle and Kovar, 2008, pp. 334-342)
All over the world, people suffer from a wide variety of mental illnesses. Not only is a mental health condition difficult to manage, but also, both the associated stigma and stereotyping are difficult to handle. Affected people are often denied basic needs such as decent work, safe accommodation, health care and belonging to social groups. Part of the stigma is that those affected turn against themselves. This phenomenon is called self-stigma. The stigma consists of three components: the stereotype, the prejudice and the discrimination. Stereotyping in particular, is seen as the main factor, since the social structures are learned by all members of a society. This includes negative attitudes towards those affected to whom dangerous, inadequate and incompetent stereotypes are attributed. Prejudices include a general negative emotional response, and discrimination is behavior that relates to prejudice, such as avoidance, abstention from a job etc. The situation is similar with the self-stigma. Three studies show that the majority of residents in the United States and in many western countries have stigmatized behaviors towards mental illness, even in the well-educated workforce. There are 5 hurdles to mental health care, including the absence of mental health care centers and public funding, the current form of organization, the integration of primary care, inappropriate use of human resources, and public stigma. Strategies to overcome these hurdles include protest, education, and contact. Mental illnesses are misrepresented, especially in the media. Stigma can be overcome, for example, if persons who experience reservations against the mentally ill, get to know people with mental illnesses and can convince themselves that they can make a valuable contribution to the community and pursue a profession. (WHO, no date, pp.1)
Media-related analyses of film and print mostly show three types of people with mental illnesses: the sensitive type, the intellectually impaired type and those who are responsible for their condition. 18 46% of the evaluated material describes hostile behavior by family members, 62% highlights social exclusion in the circle of friends and 35% describes the stigma from which those affected are confronted at school or at work. This manifests itself in fear, discomfort, avoidance and underestimation of one's own ability. An analysis of English-language films published between 1990 and 2010 showed that most schizophrenic characters show violent behavior, a third of these characters are dangerous to the public and a quarter commit suicide. The so-called „Time to Change“ campaign has its roots in the UK, it educates through blogs, videos, advertisements and events. (Corrigan and Watson, 2002, pp. 16-20) Results from two independent studies summarize the prejudices of more than 2,000 British and American citizens against mental illnesses as follows:
1. Anxiety and exclusion: mental illnesses are dangerous and should not have a place in the community.
2. Authoritarianism: People with mental illnesses are irresponsible and decisions should be made by others.
3. Benevolence: People with severe mental illnesses are childish and should be taken care of.
Discrimination results in four steps: reluctance to help, avoidance, compulsory treatment and closed facilities. (Davey, 2013, p.1)
Stigma can lead to psychological stress, social withdrawal, secrecy and reduction of self-esteem. One of the most important models of the eudaimonian psychology of well-being includes self-acceptance, relationships with others, autonomy, mastery of everyday life and the socio-economic environment, personal growth and purpose. Stigma leads to lower satisfaction, less social support and a general feeling of hopelessness. Above all, the feeling of being less valuable and different seems to play an important role in stigmatization, which in turn increases the tendency towards depressive moods. The most important thing is to fight feelings of alienation. Improving self-acceptance and other positive psychological factors has a positive impact on overall satisfaction and emotional balance. Empathy in particular reduces discrimination and the perception of being different. (Pérez-Garín, Molero and Bos, 2015, pp. 228)
THERAPY AND THE FUTURE OF PSYCHIATRY
Social constructs around mental health have changed a lot over the decades. In addition to fear, fascination and ignorance, it is now necessary to develop a new perspective on psychiatry in postmodern times. Before the 1950s, people with a mental illness were locked away. Later the first generation antipsychotics (chlorpromazine, fluphenazine and haloperidol) gave hope to being able to treat the positive symptoms such as hallucinations and delusions. In this way, people could stay and be treated in their social environment, the outbreaks could be reduced and the quality of life improved. However, strong side effects dampened joy, and optimism declined in the 1970s. Second generation antipsychotics have far fewer side effects in the areas of motor functions and metabolism. (Dave, 2016, pp. 108-117)
There are many medical advances in the 21st century. The myths surrounding psychiatry are formidable and difficult to eradicate. However, addicts and mentally ill people are part of our everyday life, they are encountered on the street where they are frequently avoided. Setting up a psychiatric clinic in cities is a difficult task. Mindfulness and acceptance therapy can promise help, since those affected learn to deal better with the symptoms and act preventively. 42 The Vulnerability Stress Model, developed by Zubin and Spring in 1977, shows a connection between genetic predisposition and stressful environmental events or life situations. A combination of medicinal and family-related therapy has proven to be groundbreaking. According to Zubin and Spring, psychoses are also a result of external stress factors and individual disposition. Drug use and adverse family circumstances can often be mentioned as so-called stressors. However, pharmaceutical treatment alone falls short in psychotic disorders. Psychotherapy assists patients in changing the negative thought patterns about themselves. Active coping strategies with positive and negative symptoms and the relationship between perceptions, emotions and behavior needs to be improved. It should also be a goal to replace the cognitive mistakes and misinterpretations that previously led to feelings of shame and guilt with positive ones and to permanently change established thought patterns. In addition, new behavioral strategies have to be learned, e.g. breathing techniques, early detection of symptoms, sleep behavior, impulse control etc. New goals have to be set and existing systems have to be released. If there is a drug addiction, its treatment should also be given high priority to avoid relapses. Patients can be supported by identifying the connection between stressful life events and the root of the psychosis itself. Emotional recovery should include developing personal skills such as acceptance, understanding, self-reflection, and introspective awareness to overcome the associated trauma and stigma so that personal and professional goals can be attained. (Gíraldez and Fernández, 2011, pp. 33-47)
In the future, diagnoses should be made much earlier than is currently the case to initiate preventive measures. The goal is to slow down the course of the disease. Almost every week, new genes are localized in neurological research. This in turn leads to the use of specific, bio-technologically managed, disease-altering pharma co-therapeutics rather than the use of symptom-controlling drugs and measures. Neuroplasticity should also be given increased attention. Structural tissue shrinkage has been discovered in patients with psychosis, mania, depression, or anxiety disorders in recent years. These findings go far beyond the previously assumed influence of chemical imbalance. The studies describe a process in which changes occur, among other things, in the neurons and synapses, with a reduction in the number gray and white cells, which severely limits the networking and functioning of the brain. As a treatment, antioxidants could help neutralize free radicals, as could tumor necrosis factor inhibitors. Neurostimulation using electro-convulsion therapy has also been a popular method for treating neuro endocrinological disorders for decades. The next step in this regard would be a “deep brain stimulation”. (Nasrallah, 2009)
WELLNESS IN ILLNESS
Wellness in illness. These two terms are very common in economic or social topics. Recently they also started to appear increasingly in the field of architecture. Wellness is applied in a context that expresses mental, physical and emotional health as well as general joy. It is used in many health-related practices. (McMahon, Williams and Tapsell, 2010 pp. 4-5) In the „Duden“ you can find the synonyms health, well-being, wellness and eudaemonia. This includes not only good physical but also mental well-being. Illness is understood to mean a physical, mental or psychological disorder. Synonyms are discomfort, suffering, disorder, ailment, malaise, and many more. (Duden, no date, pp. 1) Well-being or wellness is an approach in which risk factors are identified and an attempt is made to prevent them at an early stage. It is a constant effort to improve health and thus improve the quality of life, achieve general well-being, in order to prolong life. From social, physical, emotional, intellectual, to spiritual well-being, this term comes into play. Health problems are often chronic in many western nations. Well-being and illness are not dichotomous states, from which one can choose one or the other. Many patients live with serious diseases such as diabetes, arthritis, asthma and high blood pressure, and yet they would describe their condition as well-being. Wellness is a feeling that can be described and experienced in both illness and health. (Fulton, 2013, pp. 2-3) Wellness is a dynamic lifestyle that includes self-care, healthy eating habits, stress management, physical fitness and sensitivity to the environment. In ancient Greece, health was influenced by factors such as lifestyle, climate, air quality, water and nutrition and was understood as a harmony of these factors. During the 17th century, Dolfman confirmed that health and disease are the extremes of the two ends, without the presence of one the other cannot be defined. (Ancheta, 2015, p. 3) Mackey describes a “here-and-now” feeling of wellness, in which the perception of the body and time have priority. Finding meaning in life during a serious illness can also be defined as a form of wellness. (Moreno-Lacalle, 2015, p.3)
In most cultures, a behavior of so-called weakness for plants can be observed by its participants. Grave drawings from ancient Egypt and the remains of Pompeii show that humans cultivated plants in their houses and gardens as early as 2,000 years ago. This behavior is a response to the biophilic affinity of human thought. The first hospitals in Europe were health centers in monastic communities, where the garden was seen as an essential part of the healing process. However, over the centuries there has been a decline in such practices until a few years ago. Now there is again a desire to bring green areas into an otherwise sterile environment. The idea behind it is simple: nature should help to support or accelerate the healing process. Our built environment is changing to one that tries to establish a connection with nature. Plants have been given an important role throughout evolutionary history. They have been considered a food source, they have been used to build shelters, and they have been an indicator of water. The continuous loss of green space can be understood as a mismatch. The human brain in particular appears to be particularly vulnerable and, because of its complexity, it takes a long time to mature. This vulnerability can explain why mental illness is very common in western nations. Knowing the evolutionary background of what plants once meant to us, one can derive that closer contact with the green environment has a healing effect. An abundance of plants reduces stress. Stress leads to a reduction in general well-being and can trigger anxiety. In addition there is a certain relevance of visual input. The beauty of plants satisfies the human mind and thus makes a positive contribution to the overall well-being. Furthermore, natural elements have a regenerative effect and restore mental capacities. Of course, other unconscious factors play a role that have not yet been researched in more detail, such as the possibility that a lack of plants could propagate an “unnatural” environment, which in turn triggers uncertainty and stress. Other non-visual aspects of plants are the fragrance, better acoustics and a positive influence on the microclimate, in which they purify and humidify the air. A stay in nature correlates with increased physical activity, socialization and acts as an escape from everyday life. Therapeutic horticulture seems to be very effective, especially for people with mental illnesses. Since, in the western world, we spend most of our time in closed rooms, the question arises what effect plants have on our well-being. For example, indoor plants can reduce the number of sick days of employees. “Places, too, can have an effect on healing. If you are living in dark, cramped, crowded quarters where noise is constant you will be stressed. If you are isolated, far from friends and family, you will be stressed. In such cases your immune system is burdened and the healing process slows. Wherever you are in the course of illness or healing, your physical surroundings can change the way you feel and, as a result, can change how quickly you heal. In all these contexts, communication between the brain and the immune system is vital. ” (Sternberg, 2009, pp. 102-132) Several studies have shown that plants increase the attractiveness of a room and reduce the level of stress, not only in sick rooms but also in windowless work areas. Plants are positively distracting and could also reduce the sensation of pain. Their use should be increased in hospitals and rehabilitation clinics. (Grinde and Grindal Patil, 2009. pp. 2332-2343)
CITY AND PSYCHOSIS
Why do psychotic outbreaks increasingly occur in cities? There is a keen interest in the latest findings, which make it clear that schizophrenia and other serious mental illnesses are more common in urban areas than in rural areas. How can architects make a positive contribution to this problem? In urban environments, there is often no opportunity to relax or there are no safe hideaways. There is still relatively little known about psychosis, so far only a direct connection between taking dopamine receptor blocking drugs and symptoms such as hallucinations, delusions and violent behavior has been established. However, the built environment may also have an impact on the release of dopamine. The connection between the environment and the human brain is stronger than expected. More than 95% of adult actions and thoughts are not the end result of cognition and planning, but count as precognitive automatic responses. You can recognize automatic impulses to a certain extent, while others are completely inhibited or are contextually adapted. People with a weak inhibition due to mental illness, drugs or biological damage to the frontal lobe are less able to suppress these environmental stimuli. "The more salient a trigger, the stronger the neural event potential and the greater a person’s inhibition needs to be to prevent an inappropriate reactive action." (Sternberg, 2009, pp. 56-57) The built environment can also be psychotoxic, because design tries to get answers, it wants to impress and change behavior. No matter whether it is an advertising board, a display or a building. There is increasing evidence that severe psychosis can be traced back to repeated attacks from negative and demanding emotional experiences. Of course, these triggers influence the mind constantly, but only when our natural abilities to sort and process them are inhibited due to various factors, an illness occurs. So it seems that psychotic outbreaks occur more often in cities, because design is more pronounced in urban areas than in the country side. (Golembiewski, 2017, p. 7) Another risk factor for psychosis is cannabis or general drug use, which is more common in urban areas. Some studies make it clear that the physical environment in inner-city locations help reinforce mental illness, e.g. increasing the risk of schizophrenia. These factors include social disadvantages in childhood such as unemployment of the parents, poor education, growing up in a single-parent household, little income, poor living conditions and a low socio-economic status. It should be noticed that a genetic predisposition is also crucial in the occurrence of mental illnesses, and the population density is much higher in cities. (Heinz and Deserno, 2013, pp. 187-197) The topic of cities and psychosis is important, as in 2050 up to 66% of the world's population will live in cities and urban agglomerations. Furthermore the rate of depression and anxiety disorders is also increased. Growing up in a city doubles the chances of children suffering from psychotic symptoms. Crime and social withdrawal are the biggest risk factors. “This [study] adds to our own experimental evidence that strongly leads us to suspect that being in the city does something to a specific circuit in the brain that impairs your ability to deal with social stress,” according to Andreas Meyer-Lindenberg. People living in cities show greater activity in the amygdala and in the cingulate cortex (brain regions that play a role in the processing and regulation of emotions) compared to people in rural areas. It should also be noted that life in cities generally favors weaker mental health. (Kwon, 2016, pp. 1-2)
TEMPLE OF ASCLEPEION
Asclepius was the god of health and medicine in ancient Greece. He was symbolized as a snake. From the 9th century BC onwards the temple cult flourished in Greece. Under Augustus ’rule, more than 300 such temples were built in the Roman Empire. Religion was closely linked to everyday life, therefore people believed in supernatural powers that ruled the universe. Life revolved around the rhythms of rituals and festivals. The “Asclepieion” consists of a small temple, an altar and two halls. Many of the temples (naós) had a vestibule that led into the interior. This room (cella) had several tables (trapezai), heaped with offerings of food. There were often sculptures made of wood or marble of the respective god. Another important element was the altar, which was outdoors. Animal sacrifices were conducted frequently on this altar. The abaton or the Dorian Stoa was considered an incubation hall for visitors, because some stayed overnight and hoped for a cure. This “pure” hall mostly consisted of a narrow, open corridor lined with Doric columns. (Warwick, no date, pp. 1) Inside was the Ionian Stoa, which served as a catagogue, a guest room reserved for important visitors to the shrine and priests. There were marble door frames in Ionian style, with strong relief decorations. Frequently there was an adjoining bathhouse. Later there were separate visitor accommodations nearby for special occasions, some of which were temporary structures for priests. Stadiums, theaters and sports areas were also found in larger healing centers. Over the centuries, the healing temples turned into a kind of spa, with hot and cold bathing areas for visitors. Another focus of treatment was interpreting dreams and prophesying oracles. In the 20th century, these ancient methods returned. Psychoanalysts such as Freud and Jung were increasingly interested in the cult of Asclepius when they were looking for the spiritual roots of healing. Ancient Greek rituals have all the important elements for a successful healing of the body and mind: the sick give themselves completely into the power of a healing, accompanied by a safe place that promises attachment, care and preparation. This happens through cleansing, fasting, dietary changes, silence, rest and meditation. The incubation site is like a black, dark background, where you abandon time and space. Patients experience healing words and touches, communicate deep feelings to the healer and experience a spiritual rebirth. (Risse, 2015, pp. 1-19)
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Die Psychiatrie ist ein komplexes Feld. Sie spannt sich über jene aus, die keinen anderen Ausweg sehen, über jene die dringend Hilfe für ihre mentale Gesundheit benötigen. Ohne zu urteilen muss sie Geborgenheit spenden. Alte Vorstellungen sind längst überholt. Die Orte sind nicht kalt, leblos oder feindlich. Psychiatrie gibt Stabilität. Psychiatrie ist mehr als medikamentöse Behandlung. Sie ist hell und umsorgend. Sie schützt anstatt zu verstecken.
Dieser Psychiatrische Krankenhausbau soll zurückbringen was verloren gegangen ist. Die Räume sollten klein und heimelig sein, denn intimste Gedanken werden mitgeteilt. Es fällt den Betroffenen sehr schwer sich zu öffnen. Architektur muss dazu beitragen. Sie muss einladend sein. Sie muss den Patienten Vertrauen ins Leben, Vertrauen in sich selbst schenken. Natürliche Materialen, lichtdurchflutete Korridore, beseelte Räume und begrünte Höfe. Wunden und Schmerz müssen gezeigt werden. Man braucht kein falsches Versteckspiel.
Ich meine Psychiatrie sollte sich unter uns abspielen. Die Gesellschaft darf involviert werden, das Stigma muss überwunden werden. Ohne wenn und aber. Krankheiten sind ein Teil unserer Existenz, und mentale Gesundheit ein oft sehr schmaler Grad. Das Stigma zu überwinden bedeutet auch Türen zu öffnen, den Menschen ihre Angst zu nehmen, mit Vorurteilen aufzuräumen und dass um es dir leichter zu machen dir frühzeitig Hilfe zu suchen. Eine psychiatrische Klinik muss das und noch vieles mehr können.