SUMMARY OF "Healing Spaces, The Science of Place and Well-Being", by Esther M. Sternberg, M.D.

OUR BRAIN & SPACE

Our sense of place is created through what we see and feel and smell and hear – through all our senses. It is created and re-created in memory each time we experience and reexperience a place. Emotions, both good and bad, become attached to a place, which can then evoke myriad layers of feelings when we come back to it: the sense of calm that we call home; the thrill and anxiety that we associate with something new; the dread of reexperiencing trauma that once happened there; the longing for a love that we experienced there many years ago. A place can trigger unhappy memories or bad habits without our realizing it. In turn, some places, which we have learned to associate with safety, can rescue us in times of need. Each of these emotions triggers cascades of nerve chemicals and hormones, which are released through the outflow of pathways of the brain. These in turn change immune cells ability to fight disease or heal, and all affect our health.

The brain searches for and identifies landmarks as we move through space. Landmarks are very important in our memories of place and space. A landmark needs to be big enough to be seen from a distance and different from its surroundings, so that it stands out. It needs to evoke some positive associations in order to draw you toward it. And it needs to be memorable. Memory of place and space mostly occurs in the hippocampus and a collection of adjacent structures, including the amygdala.

A psychiatrist and neuroscientist at Columbia University showed that rats and mice can learn to associate a particular context with safety if they repeatedly find that negative experiences don’t occur in that particular place. Context can evoke other kinds of positive memories. Animals can learn to associate a place with an additive drug. The different contexts that the rats learn to associate with a craving can be complex and include the colors and patterns on the walls, the textures on the floor, the lighting, the sounds, and the smells. The wallpaper of the test chambers may be horizontally or vertically striped; the floors either cork or tile; and the lighting of various colors and brightnesses. The rat learns to associate the addictive drug only with the chamber in which it received the drug and only with the specific features of the place. An animal can learn to associate a place and its features with any reward – food, drugs, water, exercise.

When you are sick with an inflammatory or infectious disease and are producing immune molecules to fight infection, your memory of place is impaired by the immune molecules. If you are then sent from one department to another in a healthcare facility, your ability to form a memory of the route may be impaired. You may be less able to recognize the landmark along the way. And if you don’t recognize where you are, you might lose your way and become anxious. Why not, then, design healthcare facilities taking these scientific principles into account? They should be designed in such a way as to facilitate navigation. Designers can design hospital or senior housing rooms so that there is a direct sightline to the toilet in the bathroom since illness affects memory of place, and the residents have no need to remember where the bathroom is – it’s in plan view. They can find their way to the bathroom on their own, and thus remain more independent.

It’s possible to design places that trigger anxiety and fear or design places to make people feel happy and secure. Most healthcare facilities still install fear. A person who is ill needs an environment that fosters calm and comfort as a means to healing. The spaces around us can and should do just that. There are places in the world where the experience of entering a place seems to have an almost miraculous ability to soothe anxiety and despair, and cure physical ills as well.

Many studies have shown that the immune system, like other physiological systems, can be trained to respond to conditioned or learned stimuli. One study gave a sweetened drink to people along with an immune-suppressive drug. When the researchers later gave that particular drink with identical-looking capsules containing no drug, they found that the participants’ white blood cells made fewer immune molecules and grew less, just as if they had received the immunosuppressive drug. The same could perhaps be accomplished with features within a space.

In healthcare facilities, the increasing emphasis on diagnosis and diagnostic equipment meant that they were devoting more and more space to machines rather than to people and healing. As healthcare facilities grew to accommodate these new technologies, so did the paths that patients had to take as they made their way through buildings. Navigation through a strange and often frightening environment, harboring unfamiliar instruments in intimidating procedure rooms, is an extremely stressful and anxiety-provoking experience, especially for someone who is ill, and already primed for fear. Add to this the blurred memory, impaired cognition, and depressed mood that immune molecules cause during illness, and stress and distress increase even more. Stress slows healing, predisposes the body to more severe and more frequent infections, and compounds the effects of illness. A healthcare environment, whose goal is to heal, should do what it can to eliminate stress.

We need to bring the mind back into the equation of health and healing and include the ways that emotions and the physical environment interact. Besides removing stressors from an environment, healthcare design research aims to add features that enhance comfort. This includes the addition of gardens, views of nature, artwork, soothing music, nature sounds, soothing colors, and spaces where family members can congregate for mutual support. This also includes “green” features such as construction materials that improve indoor air quality, open spaces, nature trails, balconies and gardens. Nature itself has a healing effect.

The Mayo Clinic’s Leslie and Susan Gonda Building which opened in 2001 features a lobby with a 3-story atrium of glass, marble and steel. Hanging from the ceiling are brightly colored blown-glass chandeliers reminiscent of sea-spray. On the walls are huge paintings and murals. The atrium also contains gentle auditory stimulation: the soothing sounds of a grand piano to fill the space. An enormous window overlooks a terraced rock garden. Seats along the glass wall face toward the garden. The overall effect is one of peace and tranquility.

The Barbara Ann Karmanos Cancer Center remodeled one of its units with soothing colors and comfortable furniture, and installed acoustical ceiling tiles. They then compared health outcomes in the new unit with those on an existing old unit. They found that in the new unit, patients used 16% less pain medication and errors decreased by 30%.

Some are trying to set a new standard for healthcare design to include single-occupancy rooms, improved air quality and ventilation, use of sound-absorbing ceiling tiles and flooring, better lighting and access to natural light, and the creation of pleasant and comfortable spaces that reduce stress including gardens, nature views, and spaces for family members. Material scientists are also developing new products which are easy to clean and make it difficult for germs to adhere to surfaces, yet are also acoustically absorbent.

An awareness of how place affects mood and behavior, and in turn our health, is helping today’s architects design places that work with our bodies to maintain health and promote healing, rather than work against us to worsen stress and disease. Space should offer soothing views of nature and just the right amount of light and color to create moods that help us heal.

The World Health Organization defines health as a “state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” The build environment affects all these aspects of health.

COLOR

The color green is perhaps the default mode for our brain because that’s the color we saw most of while evolving. It was the background we were weaned on in primordial times, the background that told us we were safe, the background that lulled us to sleep against a darkened sky. Could this be why patients in a hospital with views of trees heal faster than those with views of a brick wall? Only in very recent times have we begun to fill our landscape with colors we don’t find in nature, which in urban settings largely displace the color green: red bricks, grey concrete, black pavement, white sidewalks.

Quick recognition of contrasting colors is necessary for survival in the wild, especially in the case of animals that forage for fruit. It’s no accident that most fruits contrast starkly with the green foliage around them. How do light and color become connected to a mood? Is green naturally soothing and red exciting, or is this response something that we learn? Probably it is a little of both. One consistent finding in business and marketing research is that shorter wavelength colors such as blue and violet are more appealing to shoppers than longer wavelength colors like orange and red. As colors move farther to the extremes of wavelength, whether long or short, they become more stimulating, while those in the middle are calming.

One experiment with different colored rooms definitively concluded that blue is calming and red and yellow are stimulating. People were more hungry and thirsty in red rooms, and food and beverage consumption was twice as high in the yellow room. People in the blue room felt more calm. In the blue room, people spent more time standing around the perimeter while in the yellow and red rooms, they spent more time clustered in the middle. People in the yellow room were most animated; they moved around more, and spent more time talking and laughing loudly in small groups. They described their moods as “active,” “playful,” and “energetic.”

LIGHT

Exposure to bright sunlight or to lights that have the same intensity and wavelength spectrum as sunlight, can be used to treat patients with depression, preventing slumps in mood, restoring energy, and bringing stress hormones back to normal. If you’re clinically depressed, you probably wake up in the middle of the night for no apparent reason, feeling wide awake. When you’re awake in the wee hours, you can start to worry and feel stress. Some of this is linked to light-sensitive proteins in the eye, similar to the ones that register color.

Besides lifting moods and changing stress hormones, full-spectrum sunlight can also change the heart rhythm in people with SAD (Seasonal Affective Disorder) – not the heart rate, but rather the time intervals between beats. These intervals reflect the activation state of the nerves that speed and slow the heart - the adrenalin-like nerves of the sympathetic nervous system and the vagus nerve. Certain wavelengths of light can also shift heart rhythms in people without depression. Red and green wavelengths have a stimulating effect and blue ones are calming.

Just as sunlight can boost moods and physiological responses, a dearth of sunlight can lower them. Prolonged exposure to fluorescent lighting in the absence of natural light, a common situation in office spaces, can dampen moods in most people. There is a higher incidence of depression and mood disorders in people in northern latitudes as well as those living at the far western edge of their time zone where the sun rises an hour later than the eastern end.

Working a night shift can have deleterious effects on health. So too can spending a large proportion of time changing time zones as pilots do. Women who spend their working lives on night shift have a 30-80 percent greater chance of developing breast cancer than those who work during the day. Besides changing our moods and our behavior, light affects our immune system.

While too much light is harmful to the skin, a little sunlight on the skin is a good thing. It helps us heal. Vitamin D is one of the molecules that is activated by light falling on our skin. When fed Vitamin D, our cells spew out immune molecules that summon other immune cells, thus speed healing. Lack of Vitamin D causes weak bones, short stature, and abnormal bone growth in children. Recently there has been an alarming increase in Vitamin D deficiency in many countries. Children are developing rickets; adult women show symptoms of fatigue and weakness, joint, and muscle aches, and weak bones – symptoms that overlap with chronic fatigue syndrome and fibromyalgia, and can also include depression. The rise is due to decreased consumption of dairy products and overuse of sunblock and avoidance of the sun. This underscores the importance of balance: while too much sun can lead to DNA damage and too little can cause vitamin deficiencies, a certain amount is necessary for good health. Design can support health by providing adequate light within the space.

(This book didn’t go into how light affects our sleep quality, but it absolutely does).

SOUND

When music makes a person shift from a stress mode to a relaxed mode, the heart-rate variability shifts from the adrenalin-driven, sympathetic pattern to the more changeable pattern of the parasympathetic relaxation response. Several Swedish studies have shown that patients undergoing hernia repair who listened to relaxing music while under anesthesia, or in the recovery room for on hour immediately after surgery, required significantly less morphine compared to patients who did not listen to music: one-third to one-half the dosages of pain medication. Activating the vagus nerve, the way soothing music does, can affect the immune system. Many studies do show that listening to music has measurable effects on the production of certain antibodies in the saliva: the so-called IgA antibodies which are the first line of defense in protecting against infection. Such research suggests that music can affect not only our emotions and the emotional outflow pathways of the brain, but al the ability of immune cells to fight infection.

One of the biggest stressors in healthcare facilities is noise which increases heart rate, blood pressure, and other measures of stress. It certainly interferes with sleep – another physiological function necessary for healing and psychological well-being. Until the early twentieth century, the vast majority of patients who entered a hospital exited through the morgue, because they died from infections they had acquired while in the hospital. Then the healthcare profession realized that the design and contents of hospitals, and the building-influenced behaviors of the doctors and nurses in them, were the source of those infections. In their eagerness to rid hospitals of infection, architects and designers of the twentieth century removed all possible elements that could spread infection, including any sort of surface that could harbor germs. The only way to keep these places clean was to cover them with metal, stone, or tile – materials that are acoustically reflective. Shiny, easily cleaned surfaces amplify sound. As hospitals became cleaner, they became colder, noisier, and less comforting. “Sterile” then became a negative term instead of a positive one. What patients now crave is more attention to their states of mind and emotions, and to all things in the environment which sustain them.

White noise can help mask a noisy environment. People can block out monotonous repeated sounds, and white noise such as the sound of an air conditioner, can be relaxing. The ability of the brain to become habituated to sound has spawned a whole industry of recorded nature sounds called pink nose.

AROMA

Several studies suggest that fragrant oils such as lavender ease tension, improve mood, and induce sleep. Other essential oils that reduce stress are chamomile, geranium, rose, sweet marjoram, and valerian. New knowledge about the sense of smell and aromatherapy is being incorporated into healthcare design in a field called environmental aroma. Subtle mixtures of scents from nature could be combined with ventilation system technology to provide a pleasant experience and evoke positive emotions. The approach is already being used commercially in hotels to set a relaxing mood for visitors.

SOCIAL INTERACTION

Social interaction has also been shown to deter wound healing by increasing the stress hormone cortisol. Treating with oxytocin speeds up wound-healing, while treatment with a drug that blocks oxytocin significantly increases wound size and slows healing. There’s also evidence that positive emotions can improve health in people. Compassion meditation improves immune function. Compassion and altruistic activities are also associated with better health outcomes. People who volunteer have longer life spans and better mental and physical health. One study in San Francisco found that elderly volunteers had health outcomes over a five-year period that were 63% better than those of people who did not volunteer, even when controlling for factors such as illness, which might prevent volunteering. Other studies have shown that people with many social ties and social interactions have better health outcomes, fewer ER visits, and fewer and less severe upper respiratory infections such as the flu and common cold. Designers can design buildings and communities to encourage social interactions and thus affect health and wellness.