Hospital design reflect shift in attitudes, treatment of mental illness and addiction
CrossCurrents
Elizabeth Scott
Years of planning are about to become reality when the ceremonial shovel breaks ground for the Centre for Addiction and Mental
Health’s (CAMH) Queen Street redevelopment late summer/fall 2006. Many are wondering what is driving the planned changes.
Do they represent the start of a new era, a paradigm shift in the care and treatment of people who experience mental illness
and addiction? Are more evolved social attitudes and 21st-century treatment outcomes fueling psychiatric institution redesign
in general?
When it initially opened in 1850,the Provincial Lunatic Asylum sat an hour’s buggy ride from the Town of York, as Toronto
was called. An act passed in 1839 had authorized the asylum’s construction, and architect John George Howard designed what
was in its day the largest public non-military building in the nation.
Expectations for care were, if not for full cures, then for healing in an environment focused on “health, comfort, security
and restoration,” as described in the 2000 book The Provincial Asylum in Toronto: Reflections on Social and Architectural
History. Designed to deliver the new “moral therapy” among quiet farmlands, away from town, patients were isolated, but at
least were no longer hidden away in ramshackle pens in barns, or in jails.
As years became decades, cures and good outcomes for the asylum’s patients were few and far between. Fast forward to the 20th
century. Renamed in 1919 the Ontario Hospital – Toronto, the facility became overcrowded. The arrival in 1953 of the first
neuroleptic medications led to deinstitutionalization through the sixties, but supports in the community didn’t come close
to meeting patient needs. Demolition of Howard’s masterpiece and construction of new buildings in the seventies was perhaps,
at least in part, an attempt to forget failures of the past and start anew.
Today, despite current knowledge, more successful treatment options and better outcomes, the stigma of mental illness and
addiction lingers on. In fact, it prevents many who experience mental health and addiction issues from getting help – a problem
today’s redevelopment planners are keen to address: “Before we had drawings or ideas, we collected people in the community–
health care professionals, CAMH staff, clients/patients, over 200 interested parties –and ran workshops,” says Frank Lewinberg,
partner in the Toronto-based architectural firm Urban Strategies and CAMH’s redevelopment master planners. “Coming out of
that process, it was very clear that the most important thing we faced was stigma. The whole notion became to ‘disappear’
the institution, to make it go away so you don’t see it as different from any other part of the city.”
And so, not unlike some David Copperfield illusion – but in a permanent way – the goal became to develop strategies to “disappear”
CAMH. One of those strategies? To “un-isolate” the acreage by extending the existing neighbourhood streets and creating a
new avenue to form a grid of new city blocks. Another strategy? To construct on those blocks buildings for non-hospital uses
that fit naturally into the surrounding cityscape, including other kinds of residences, cafés, research buildings, perhaps
a grocery store and buildings or businesses appropriate to and compatible with CAMH. Terry Montgomery of Montgomery Sisam,
one of the architectural firms that make up the consortium working on Phase I of the redevelopments says, “Rather than CAMH
being in a building in the middle of an acreage or a campus, there will be a building that is simply an address on a street...
The site is approximately 2.4-million square feet, half of which will be non-CAMH – not hospital at all.” Instead of one street
address, as is currently the case, there will be several. “That’s the integration idea,” adds Alice Liang, also of Montgomery
Sisam. “We always say normalization is at the forefront, not making CAMH exactly disappear, but making it no different from
the surroundings.”
This style of multi-use purpose integration is occurring at other psychiatric hospitals as well. In London, England, for example,
at the South West London and St. George’s Mental Health NHS Trust’s Springfield site, a similar transformation is taking place.
According to Andrew Simpson, director of planning, “Historically, Springfield Hospital’s purpose was to facilitate the exclusion
of the mentally ill, and that was defined very broadly. Now, what I see philosophically, what we are doing, is that we are
historically reclaiming the asylum. We are quite deliberately building a new bit of London around the asylum, reversing the
process of exclusion. We are building an inclusive community to include people who are experiencing acute mental health problems
and, in a sense, ensuring that the local community do not exclude them – because they [the patients] will be there.”
Like CAMH, Springfield is constructing non-hospital buildings on its site to bring society to its doorstep. Springfield is
also restoring the original 1840 buildings. The high-ceilinged buildings are being completely renovated into expensive housing,
condominiums and “mansion blocks.” Money raised from the sale of those high-end properties will be used to rebuild the hospital,
says Lewinberg, who is also master planner for the Springfield site. Heritage/landscape gardens and heritage trees, protected
under British law, will also remain. At CAMH, parks with beautiful stands of trees and open spaces, healing qualities of the
natural environment, will stay as well.
“For both Springfield and CAMH, the master plans are not real estate master plans; they are mental health treatment plans,”
says Lewinberg. “What is being shown on the ground derives from treatment goals.” In other words, knowledge about how removal
from society has under-mined recovery from mental illness and addiction is being addressed through there design: “The notion
of keeping a mental hospital as an isolated thing is breaking down, even as a treatment model,” Lewinberg says. “People who
are being treated there feel like they are not part of the community. So the idea with CAMH and Springfield is to integrate
the community onto the site.”
Much thought and research have gone into the planned look of the buildings because “things like building heights, densities,
green space and organization of roads contribute to either creating mental stress or generating good mental health,” says
Simpson. For CAMH, Montgomery says, “We were studying buildings around Toronto for a lot of reasons – seeing how big buildings
can be made to feel slender and smaller scale,” to create less intimidating and more inviting structures. Residential core
bed buildings will have outdoor terraces right off the unit so that if people have to stay on the unit all day, they have
a big terrace with trees and shrubs they can access. Alternate Milieu non-acute care buildings will have comfort-able home-like
rooms and inviting shared spaces to encourage people to leave their rooms, says Montgomery. “When they leave their rooms,
they will have all sorts of choices: They can stay on the unit, prepare some-thing in the kitchen, sit in the quiet areas
or busy areas, go to the garden. It’s having those choices that is important.”
Judith Tompkins, executive vice president of programs, and chief of nursing practice and professional services at CAMH, says
the new-style mental health care delivery aims to empower clients: “When we talk about creating an urban village on the CAMH
site, we’re talking about trying to establish an even greater fit with the community – a flow between hospital and community,
in a way that says to clients, ‘Yes, you may have a mental illness or an addiction, but that, too, can be a part of life,
like a physical illness. It shouldn’t mean that you suddenly are cut off or set apart from the community.’”
Through empowering and inviting clients to participate more in their care, the journey toward regaining optimal mental health
will be more fully supported, says Tompkins. “It’s about a much more collaborative, client-centred and empowerment approach,”
she says. “In the past, when people came to hospital, we kind of took over their lives. Now we want them to maintain as much
control in their lives as possible and not lose sight of their families and community connections.”
Janine Robb, administrative director of the Mood and Anxiety and Women’s pro-grams at CAMH, agrees: “We are shifting our perspective
on what care is. Rather than being illness-oriented and focusing only on treatment and the medical part, we’re emphasizing
a recovery base. It’s a complete cultural shift in care.”
And so it seems that, yes, a paradigm shift in the care and treatment of people with mental health issues is finding expression
through facility redesign. According toDr.Paul Garfinkel, president and CEO of CAMH, the new site will “support client dignity,
recovery and transition back into the community, while integrating the best in clinical care, research, teaching, health promotion
and policy at one site.”
Centre for Addiction
