Bibliography « Therapeutic Landscapes Network

“How the City Hurts Your Brain (and what you can do about it)”

January 22, 2009 | by Naomi Sachs

Yoko Shimizo for The Boston Globe

An excellent article by Jonah Lehrer appeared earlier this month in The Boston Globe: “How the City Hurts Your Brain…and what you can do about it.”

As I mentioned a few postings ago, designers – including the “father of landscape architecture,” Frederick Law Olmsted – have known for a long time that cities, though stimulating and full of opportunity, can also be rife with disease, pollution, and other health-defeating problems. Now scientists are examining the effects of the city on the brain, and they are finding what many people intuited all along: “Just being in an urban environment…impairs our basic mental processes. After spending a few minutes on a crowded city street, the brain is less able to hold on to things like memory, and suffers from reduced self-control.” (I think the brain would suffer anywhere when left out on its own, but never mind).

So that’s the bad news. The good news is that even in an overstimulating urban environment, you can counteract the overwhelm that leads to cognitive disfunction by going to a park, or even by paying closer attention to the nature that is all around you (see my post on Urban Naturalism). Lehman discusses attention restoration theory, or ART, coined by University of Michigan professors Stephen and Rachel Kaplan more than twenty years ago. Nature elicits what the Kaplans call “soft fascination,” a type of attention that allows for reflection and that is actually mentally restorative rather than taxing. Even just viewing a nature scene – or a tree, or something other than concrete and brick and soot – from the window is beneficial. Now we know why CEO’s always get the corner office!

To those of us in this field, not much of this is new information, but we’re always thrilled when people stand up and take notice. The Boston Globe! Usually we end up preaching to the converted in tomes like Environment and Behavior (great journal, but not so accessible to those who aren’t designer/environmental psychologist geeks). Lehrer’s article is a great primer on the restorative benefits of nature and bears close reading. For those who want to follow up with further research, Lehrer cites some key studies, and of course the Therapeutic Landscapes Database and Blog have lots more where that came from.

Oh, and here’s a link to one of the articles mentioned by Lehrer:

“The Cognitive Benefits of Interacting With Nature,” by Mark G. Berman, John Jonides, and Stephen Kaplan in Psychological Science, Vol. 19, No. 12, pp. 1207-1212.

The need for natural light, part III

January 5, 2009 | by Naomi Sachs

Let’s see, which hospital room would you rather stay in? This one (A)?

Or this one (B)?

Carson Tahoe Regional Medical Center, Carson City, NV

As for me, I’d choose B. There are lots of reasons why I think B is better than the A, but high on the list is that B has lots of windows that not only look out onto a view that even homebuyers would pay good money for, but that let in copious natural light as well.

And so we come to the Part III of “The need for natural light.”

The benefits of natural light – at home, at work and school, and in the healthcare setting – have been well documented. People fare better when they have access to natural light. For example, a 1998 study found that sun exposure in the workplace environment increased worker satisfaction and performance, including lowering intention to quit and reducing fatigue (that same study, by Leather et al., found that providing views of nature also increased satisfaction, particularly in high-stress environments). A landmark “Daylighting in Schools” study found that students in classrooms with more natural light scored as much as 25% higher on standardized tests than other students in the same school district (see references below for full citation and to link to the condensed study).

As for healthcare: Roger Ulrich and colleagues have found exposure to natural light to be an important factor in environments for healing. Exposure to sunlight can reduce depression, alleviate stress, and even reduce pain. In addition to providing essential dosages of Vitamin D, sunlight increases our levels of serotonin, which in turn inhibits pain. In their recent literature review of evidence-based healthcare design, Ulrich et al. cite a study by Walch and colleagues of post-operative spinal surgery patients. Patients with sunnier rooms reported less stress and took 22% less analgesic pain relief medication (see Ulrich et al, 2008, below).

In her new, excellent book A Visual Reference for Evidence-Based Design, Jain Malkin lists daylight as one of the key ingredients in creating a successful Environment of Care: “There is a major focus on the importance of natural light and views, access to gardens, and clarity of wayfinding.” In Chapter 4, “Incorporating Research into Design Features,” lighting is first on the list: “Lighting–both natural and electric–is the most important component of an interior environment. Adequate exposure to natural light is essential for biological health and entrainment of circadian rhythm. Research indicates that patients in rooms that receive more sunlight are less depressed and have reduced length of stay.” Malkin also mentions benefits to staff members (pp. 63-65; see full citation below).

So what does all of this have to do with therapeutic landscapes?

Simple: Windows that let in natural light…

The waiting room at Santa Fe Cancer Center at St. Vincent Hospital

looks out onto the healing garden (Santa Fe, New Mexico)

…can also offer views to the outside world (even skylights can sometimes give us views of blue sky and/or clouds). As Ulrich et al. state in their most recent (2008) literature review, “Larger windows in patient rooms not only provide natural light, but they also have the potential benefit of offering views of nature and should be considered in the design process.”

Healing garden at St. Vincent Hospital, Santa Fe, NM

(note the mirrored windows – they provide privacy for those inside

while also reflecting the garden to make it appear larger).

And as we know from Ulrich’s and other studies, window views to something more interesting than a brick wall, or the building’s air conditioning system, elicit better outcomes. And the research also suggests that more naturalistic the setting, the better the outcome (again, see Ulrich et al, 2008, below).

Lobby at Carson Tahoe Regional Medical Center, Carson City, NV

All of this research notwithstanding, there are times when natural light can be too much of or not enough of a good thing.

Too much of a good thing:

1. When light = sun = heat. In hot climates, keeping light out is one important way of regulating the temperature. Whether inside the building or out, people seek shade when temperatures rise above the human comfort zone. Though it’s beautiful and exemplary in many ways, I’m actually not sure how I’d feel in the above Carson City lobby on a hot day in August…but maybe they’ve got it all figured out with awnings, blinds, or some other technology (besides just more AC).

2. When light = glare. For example, as I write this, the sun is starting to stream into my office, which would be lovely if it didn’t glance off of my computer screen. Time to draw the curtain. And glare can truly be a problem, especially for people like the elderly who are glare-sensitive.

3. This last point isn’t so much to do with light as with privacy. The one drawback of a window, especially on a ground floor looking out onto a garden, is that if users inside can see out, then people outside can usually see in. Designers of hospitals with interior courtyards often grapple with the double challenge of the “fishbowl effect” (feeling like everyone can see you when you’re in the garden) and not wanting to violate the privacy of those indoors. Designers have found all sorts of clever ways to address this issue, including at St. Vincent Hospital, above, where mirrored windows allow users inside to see the garden whilst keeping their privacy intact, and users outside get the sense of an even larger and more verdant garden (yep, the old mirror trick can work in the landscape as well).

Window coverings: That 1998 workplace study I mentioned earlier also suggested providing users with ways to control the amount of light (curtains, etc.). As we also know from research, providing people with choices is another way to reduce stress and bolster a feeling of control over one’s environment. Whether those operable window coverings are used to control light for temperature regulation, glare, privacy, or just personal preference, they should be provided whenever possible.

Not enough of a good thing: Seasonal Affective Disorder and Sundowners Syndrome. Sometimes natural light has to be augmented or adjusted, as in these two examples below.

1. Another issue with natural light is that in the winter, there just isn’t enough of it. We’ve all heard of SAD – Seasonal Affective Disorder, and this is a real thing. Just as plants need grow-lights in the winter because even sitting in a sunny windowsill isn’t enough, some people need additional light, too. Full spectrum light therapy, at doses of 2500 – 10,000 lux, has been found to be as or even more effective than anti-depressants for some SAD sufferers.

2. For people with Alzheimer’s and other forms of dementia, exposure to light and the color of light should be controlled and regulated to avoid mood changes and disruptive behaviors, particularly those brought on by “sundowners syndrome.” In two studies by Melinda La Garce, the effects of “Sundowner’s Syndrome” and other light-related problems were reduced by adding “full spectrum lighting to simulate daylight, shading devices to reduce sun angle change and shadows, and light monitors to keep the light intensity the same throughout the day and evening.” In the 2004 study, La Garce noted that the sun’s altitude, which changes over the course of the year, affects the color, intensity, and angle of daylight. She also found that the color of light seemed to play a stronger role than shadows and light intensity.

As I’ve mentioned in the past (see, for example, “When the Weather Outside is Frightful”), indoor atria are another great way to provide access to natural light and nature, even on days when going outside is not an option. This image is of the Fourth Floor Atrium at the University of Alberta Hospital in Canada. To see more examples, link to Shane Pliska’s article in Interiorscape Magazine.

References

Crockett, Jim (2004). “Healthy Daylight and Healthy Darkness: What our Bodies Need.” Consulting-Specifying Engineer. Click HERE to link to the article.

Darling, Tammy (1993). “Seeing the light: why your body needs regular doses of natural light.” American Fitness, Nov-Dec. Click HERE to link to the article.

Gross, Raz, Yehuda Sasson, Moshe Zarhy, and Joseph Zohar (1998). “Healing Environment in Psychiatric Hospital Design.” General Hospital Psychiatry, Vol. 20, No. 2, pp. 108-114. Read the summary by InformeDesign.

Heschong, Lisa and Heschong Mahone Group (1999). “Daylighting in Schools: An Investigation into the Relationships Between Daylighting and Human Performance.” Commissioned by California Pacific Gas and Electric Company. Click HERE to link to the condensed report.

Horowitz, Steven G., M.D. (1998). “Design Trends: Designing for Advanced Therapeutic Outcomes – Acute Care.” Journal of Healthcare Design, Vol. 7. Read the summary by InformeDesign.

La Garce, Melinda. (2004). “Daylight Interventions and Alzheimer’s Behaviors – A Twelve-Month Study.” Journal of Architectural and Planning Research, Volume 23, Issue 3, pp. 257-269. Read the summary by InformeDesign.

La Garce, Melinda. (2002). “Lighting Affects Behavior of Alzheimer’s Patients.” Journal of Interior Design, Volume 28, Issue 2, pp. 15-25. Read the summary by InformeDesign.

Leather, Phil, Mike Pyrgas, Di Beale, and Claire Lawrence (1998). “Windows in the Workplace: Sunlight, View, and Occupational Stress.” Environment and Behavior, Vol. 30, No. 6, pp. 739-762. Read the summary by InformeDesign.

Malkin, Jain (2008). A Visual Reference for Evidence-Based Design. The Center for Health Design.

van Bommel, W. J. M. and G. J. van den Beld (2004). “Lighting for Work: A Review of Visual and Biological Effects.” Lighting Research and Technology, Volume 36, No. 4, pp. 255-269. Read the summary by InformeDesign.

Ulrich, R. S., Craig Zimring, Xuemei Zhu, Jennifer DuBose, and Hyun-Bo Seo, Young-Seon Choi, Xiaobo Quan, and Anjali Joseph. (2008). A Review of the Research Literature on Evidence-Based Healthcare Design. Published in Health Environments Research & Design Journal, Vol. 1, No. 3, Spring, pp. 61-125. Click HERE to read the abstract.

Ulrich, R. S., C. Zimring, A. Joseph, X. Quan, and R. Choudhary. (2004). The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: Center for Health Design. Read the summary and access the full report at the Center for Health Design.

Walch, J. M., B. S. Rabin, R. Day, J. N. Williams, K. Choi, and J. D. Kang. (2004). “The effect of sunlight on post-operative analgesic medication usage: A prospective study of patients undergoing spinal surgery.” Psychosomatic Medicine, Vol. 67, pp. 156-163.

Therapeutic Landscapes Research Initiative (TLRI)

November 17, 2008 | by Naomi Sachs

Image courtesy Henry Domke Fine Art

People interested in evidence-based landscape design are usually underwhelmed by the amount of solid research out there. It’s hard to design a garden for, say, people with schizophrenia, when so little research has been done on this specific population. Or as another example, sure, we all know by now that people prefer lots of greenery to spaces that don’t have much plant material. But what kinds of plant material do they prefer? What colors, shapes, textures, forms? The study below discusses preferred tree forms. So although often we don’t have enough information, sometimes we can be overwhelmed by what has been published. Of the research that exists, how do we tease out what’s the newest, the most valid, the most pertinent to our specific project?

The Therapeutic Landscapes Research Initiative (TLRI) was launched as a way to try to answer these questions and fill some of the gaps. After all, designers and people in health and human services don’t have much time for research. They want answers quickly, and the more current and germane to their project, the better. Funded by ASLA and spearheaded by several ASLA Healthcare and Therapeutic Design Professional Practice Network members, the TLRI is an excellent resource. Students at Iowa State have compiled a list of the most current and relevant articles from over twenty journals and other publications, with synopses of each study that really help give a sense of what the research is about.

Here’s the link to the site: http://www.asla.org/ContentDetail.aspx?id=20272.

And here’s one example:

“Responses to Scenes with Spreading, Rounded, and Conical Tree Forms.”

This study sought to understand reactions and preferences of 206 participants to different types of tree forms. It was predicted that people would have a preference for the savanna-like spreading form. Participants viewed slides of trees that were digitally enhanced to emphasize the conical, spreading, and rounded tree forms. Measurement tools included preference questions, affective responses, skin temperature, and blood pressure. Results revealed that the spreading form was preferred over rounded and conical forms. It was also important that any tree form was preferred over inanimate objects in an urban setting. Trees, regardless of their shape or canopy density, are essential in urban environments for the well-being of the residents.” Environment and Behavior, 12/20/2007, 5 667-688.

More Useful Research on Landscapes for Health

October 23, 2008 | by Naomi Sachs

The articles from InformeDesign have been coming fast and furious (they send weekly research summaries), so instead of listing each one separately, I’m listing three at a time today (as always, click on the colored words to connect to the links):

1. Nature Improves Concentration for Children with ADHD: “Children with Attention Deficit Concentrate Better After Walk in the Park, ” by Andrea Faber Taylor and Frances E. Kuo, 2008. ” Get those kids outside! I’m sure Richard Louv and the Children and Nature Network are happy with this one. In fact, their blog points to a New York Times article about the study, which is definitely worth a look: “A ‘Dose of Nature’ for Attention Problems,” by Tara Parker-Pope for the New York Times (10/17/08).

2. Legible Neighborhoods and Dementia: “Dementia-Friendly Cities: Designing Intelligible Neighborhoods for Life,” by Lynn Mitchell, Elizabeth Burton, and Shibu Raman, 2004. While the article talks about wayfinding and legibility outside of nursing homes and CCRCs (Continuing Care Retirement Communities), many of the same points could be used for designing any environment for people with dementia, even gardens and other outdoor spaces.

3. Designing Parks to Serve Poor Communities: “Parks as Mirrors of Community: Design Discourse and Community Hopes for Parks in East St. Louis,” by Laura Lawson, 2007. This goes back to yesterday’s blog, about the TKF Foundation’s work, only this time in Missouri.

Wrote a Thesis? Share It With Others!

March 30, 2008 | by Naomi Sachs

I got an email last week from a landscape architecture student who is writing a thesis on therapeutic landscapes. She’s in the midst of her literature review, and though the Therapeutic Landscapes Database lists several theses, most of these are unpublished and not in digital format (with a couple exceptions). Sometimes schools keep copies, but they are often difficult to get ahold of once they’ve been filed away. What a shame, all that good work sitting on a shelf somewhere. It should be more easily accessible so that we can share information and learn from each other.

So, I’m putting the call out:

If you have written a masters thesis or a Ph.D. dissertation related to the subject of therapeutic landscapes, please email me an electronic version, as well as the full citation, and I will list it on the TLD References page. You can also contact me by posting a comment to this blog. Thanks, Nancy, for getting the ball rolling!

Center for Health Design Position Papers

January 9, 2008 | by Naomi Sachs

The Center for Health Design has published two good papers:

Wayfinding: Design for Understanding, written by Barbara J. Huelat, explores ways that wayfinding promotes healing, fiscal health and efficiency. In addition, other benefits of a strong wayfinding system are discussed.

Health and Nature: The Influence of Nature on Design of the Environment of Care, written by Jerry Smith, ASLA, LEED AP, reviews the impact of nature on healthcare environments. Smith also discusses the needs of various user groups within these spaces as they relate to nature.

Both are “Best Practices Papers”:

Based on the work the ESC did in 2005 for the “Environment of Care” chapter, individual members are drafting position papers on a variety of topics, including nature and wayfinding. They are available for download at: http://www.healthdesign.org/advocacy/adgroups/escouncil.php.