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Brick by Brick

By John Bentley Mays
Network, Summer 2008

This summer in Toronto, the first phase of the Centre for Addiction and Mental Health’s $382-million renovation opens for business — and reopens an old question that has haunted psychiatric hospital designers and other architectural thinkers for centuries. Do buildings influence what people think, feel and do?

The great North American hospital reformers in the first half of the nineteenth century believed they had hit on the right answer — yes! — to this important query. The clue to effective treatment, thought the leading doctors of the era, lay in designing large, imposing hospitals full of light and air, and situating them far from the city, among farms and gardens. Until its demolition in the 1970s, John George Howard’s massive 1850 Provincial Lunatic Asylum — the famous (or infamous) 999 Queen, on the present CAMH site — was Canada’s most impressive monument to this notion that architecture can influence patient care immediately and dramatically.

Such optimism soon ran aground on the reef of reality, as the mysterious, intractable diseases of the mind refused to retreat before the new Victorian architecture of healing. But though it failed in psychiatric circles, the idea that good buildings make happier people persisted elsewhere, and enjoyed a vogue down to the quite recent past.

Only a few decades ago, says George Baird, architect and dean of architecture at the University of Toronto, architectural theorists firmly believed that “if you get the building right, human behaviour will be transformed.

“Then, lo and behold! we discovered that this was a faulty assumption. There were two opposite reactions to that discovery. One was an abandonment of any interest in the relationship of built form to behaviour: since it’s impossible to figure any of this out, let’s just make beautiful objects! At the opposite extreme, you had this takeover of architecture schools by social scientists. The sociologists were put in charge, and that ended up having a deadening impact on the schools. It’s fair to say the issue is still on the table.”

But while architectural determinism failed as a general theory, it nevertheless embodied an important insight. “Intuitively we all think there are relationships between built form and behaviour,” Mr. Baird says. “That’s why I believe communicative models for the understanding of architecture are more useful than psychological ones. There are parts of buildings which are consciously absorbed by users or observers. I think we are giving insufficient consideration to the unconscious aspects.”

The message that architecture can send has been much on the mind of leaders at the Centre for Addiction and Mental Health, as the hospital has gone forward with its redevelopment plans. The new CAMH facilities are new experiments in the power of building to speed the recovery of people with mental illness and addictions.

“I certainly accept the premise that the environment will make things better or worse for a patient,” says CAMH president and CEO Paul Garfinkel. “Many of our patients also need some privacy at times, places where they can meet a family member, where they can be with other patients. Many people, when they’re ill, have lost confidence, and many others have a paranoid sensitivity about being watched or observed. You want to maintain safety and security, but you also want something that is comforting, friendly, as open as possible. We went through a phase of making asylums look like hospitals. Now our concern is with quality of life — the highest quality of life possible.”

The evidence of how well CAMH is fulfilling these ideals is in the handsome complex now nearing completion on the west side of the hospital’s historic Queen Street site. Designed by a consortium of three well-known Toronto architectural firms — Kuwabara Payne McKenna Blumberg, Montgomery Sisam, and Kearns Mancini — the group of buildings includes three residences dedicated to people who are past the acute stages of their illnesses, but not yet ready to go out on their own.

“You want to maintain safety and security, but you also want something that is comforting, friendly, as open as possible. We went through a phase of making asylums look like hospitals. Now our concern is with quality of life — the highest quality of life possible.”
– Dr. Paul Garfinkel, Centre for Addiction and Mental Health

The contrast between the old and new structures on the CAMH campus is stark. On one hand, there are the facility’s buildings from the 1950s and 1970s: large chunks of concrete and brick, dull and uninviting. Then there are these fresh, small new residences in wine-red brick and light stucco, each more closely resembling a modern, well-made apartment building than the psychiatric hospitals of yesteryear.

But the architectural difference between past and present is not merely skin deep. At the heart of the residential scheme is a cluster of six simply appointed rooms, each furnished with a single bed, a private bath and a large operable window. These suites are connected by a short corridor to a common dining and living area. The barricaded nurse’s station typical of older psychiatric institutions has been abolished: staff will do their duty in the lounge. Each six-bedroom unit is linked, in turn, to the building’s main lobby by an elevator — a touch that affords privacy to patients, and that neatly eliminates long, soulless hospital walkways. And each of the three structures has been given its own rear courtyard.

From the outset of its massive renovation, CAMH has insisted that the new buildings be normal parts of the built fabric surrounding them, elements in an “urban village” as much like an ordinary neighbourhood as possible. Among the most instantly obvious expressions of these good intentions are the red brick facades and low profiles of the transitional-care residences, which make sensible fits with the Victorian houses on adjacent streets.

“There is no mental health architecture. It should be no different from any other architecture of excellence. There should be the same elements, all the things we want in any building — views to the outside, lots of light, gardens, nature.”
— Alice Liang, project architect/principal, Montgomery Sisam

The best thing about these new buildings, however, is the attention paid everywhere to light. There are large windows everywhere — windows in rooms and corridors, window seats at the ends of hallways, wide views from every level. As managing principal architect for phase 1A of the project Terry Montgomery explains, the old logic of hospital design dictated that visitors step from the outside world directly into a cave hollowed out of a great mass of opaque masonry. The CAMH facilities he and his group have realized, in contrast, invite patients and visitors into a lobby that immediately opens toward the courtyard beyond. There is no darkness anywhere, and a fine porosity that will probably be something patients will appreciate about their temporary digs.

But these design moves are not merely aesthetic. They express a philosophy of healing that emphasizes the connection of patients with the larger community, and that seeks to bridge the often terrible gap that mental illness and addiction open between self and society.

“Our objective was to make [the transitional care units] as home-like as possible,” says Alice Liang, a design associate with Montgomery Sisam who is the project architect/principal for this phase of the project. “Our challenge was how to normalize the internal environment. All hospitals nowadays are trying hard to blur the line between hospitality and hospital. The lobby, for example, must be very welcoming. The first impression has to be about quality. Furnishings may have to be indestructible, but that shouldn’t be the message they send.”

In a bid to incorporate CAMH’s mandate into brick and mortar, Ms Liang and her architectural colleagues surveyed new models of therapy and hospital design around the world. Their inquiry led them to an interesting conclusion.

“There is no mental health architecture,” says Ms Liang. “It should be no different from any other architecture of excellence. There should be the same elements, all the things we want in any building — views to the outside, lots of light, gardens, nature. But the details of how the space is articulated are more intense [in psychiatric architecture], depending on the program, from mood and anxiety disorders, to forensic.”

As we have it in the new transitional-care buildings, the CAMH overhaul is trying to embody the best contemporary wisdom about mental health care, and about the structures in which that care is provided. If Mr. Baird is right — if indeed hospital buildings are media that communicate messages about well-being and health — then the CAMH build-out may be on the right track. We will certainly have many opportunities to find out if it is, as this project gradually unfolds over the next dozen years.

John Bentley Mays is architecture columnist for the real estate section of the Globe and Mail.

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