‘The Salutogenic City’ – Design for Health on a Large Scale

January 25th, 2018

Clare Cooper Marcus and I wrote this article, The Salutogenic City a couple of years ago. It was first published in World Health Design. Clare was, of course, also my co-author for the book Therapeutic Landscapes.

The term ‘salutogenesis’ comes from two Latin words: salus, meaning health, and genesis, meaning origin. It was coined by Aaron Antonovski in 1979. More recently, Alan Dilani, founder of the International Academy of Design and Health, used the term ‘salutogenic design’ to mean design that promotes health and well-being rather than just addressing what is already sick and broken. You could also call it preventive design. This is more of a public health stance than a medical stance and is being widely embraced in healthcare and, thankfully, in design at many scales.

The Salutogenic City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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“From Memory to Memorial” – Book review by Lisa Horne

September 10th, 2017

In memory of the lives that were lost, saved, and changed forever in the attacks on September 11, 2001, here is a review of Bill Thompson’s recently published book, From Memory to Memorial: Shanksville, America, and Flight 93. Thank you, Lisa Horne, for this review.

“We Did Not Forget” – Book review by Lisa Horne of From Memory to Memorial: Shanksville, America, and Flight 93 by J. William Thompson

Bill Thompson is personally grateful for the passengers’ heroic charge that ended in Flight 93’s crash in Somerset County, Pennsylvania on September 11, 2001. He was only six blocks away from what was likely the target of Flight 93’s hijackers on that fateful day. In From Memory to Memorial, Thompson explores personal and professional questions through this narrative of the people and events in the creation of the Flight 93 National Memorial following the events of 9/11. The prologue establishes many themes: the role of temporary tributes, elusive closure for the victims’ families, the appropriate expression of a memorial, and the causes of the extended delay in building this particular memorial.

Photo courtesy of the National Park Service

The first chapter opens with vignettes of where residents of Somerset County were that day as they saw the airplane, and moves progressively through its descent to close with the two metal scrap cutters who actually witnessed the impact. Events unfold as they would have been experienced. Where is the airplane? There must be one. Where are the bodies? There are none. As the narrative progresses, we see it through the eyes of the first responders, who come to realize that the smell of burning flesh and the small pieces of scrap metal littered everywhere is all that is left. Most, but not all, of the human remains have been vaporized into the tree canopy, into the land. The text is visceral, raw, and immediate.

Most journalists miss the influence of land on culture while many designers, who understand these things, cannot express it well or communicate the emotion and nuances of these dynamics. With past experience as Editor-in-Chief of Landscape Architecture Magazine for nearly a decade, Thompson exemplifies both skillsets so that the reader can experience the interconnectedness of the landscape and the people who live on it. The book traces the history of the nearby village, Shanksville, from the late 1700s to the present day and underscores how the farmers’ value of cooperation became a bedrock of the community’s way of life. The theme runs like a ribbon through the book in the village’s efforts to provide support and comfort to the victims’ families. Within this backdrop, we understand and applaud as Wally Miller, the county coroner, tells news anchor Katy Couric that she cannot film the crash site. It is sacred ground containing the remains of the heroes of Flight 93.

Photo courtesy of the National Park Service

Alongside the minute details of the events unfolding after the crash of Flight 93, there are larger implications at play. Since there is little information and no survivors, the motive of the brave passengers is unclear. Was it self-sacrifice? Are some of the passengers heroes or are all of them heroes? What defines a hero? These questions are painful, but important for the American culture and for the expression of the memorial. Thompson takes the reader through these different considerations and sensitively presents different views. Memorials are built so that we remember what we can easily forget. What about the phenomenon of visitors leaving behind temporary, mass produced objects such as hats, teddy bears, and flags with messages marked on them? How do we preserve these? Some of these questions do not have resolution, but Thompson shares how all of it unfolded for this memorial site and also adds perspectives from Erika Doss, an American studies scholar on temporary memorials and Rhoda Schuler, a theology student who connects the behavior with the theory of an American civil religion.

The last half of the book focuses on the events around the design and construction of the memorial. Much of it was unprecedented. A summary of outcomes for places of mass tragedy by a cultural geographer Kenneth Foote identifies three outcomes: obliteration, designation, and sanctification. Places of mass murder are rarely sanctified with the exception of the site of the Oklahoma City bombing. It is not coincidental that the Oklahoma City bombing memorial and its design and construction process served as a precedent for the Flight 93 crash site. We also learn that memorials are often either heroic with overt symbolism such as the National World War II Memorial or minimalist and understated as with the Vietnam Veterans Memorial.

Flight 93 National Memorial Map

It was important that the process of selecting the memorial be through a competition open to any and all although, as Thompson reminds us with an experienced perspective, only the skilled professionals had a realistic chance of winning. Thompson summarizes the differences and major themes of the five final entries and explains the jury’s selection process. We can fully understand how they came to select the entry that they did even though there was early concern about the way the design might be perceived. The final entry, of course, eventually led to a considerable controversy with its Crescent of Embrace that was compared to the symbol of an Islamic crescent. In the end, the designer adjusted the design to be a Circle of Embrace with some additional trees. Not having yet seen the memorial myself, I appreciated the site description from Thompson’s visit during the grand opening and his assessment of how effectively the design achieved its original intent.

The immersive details in the book, and the inclusion of dialogue and quotes drawn from hundreds of oral histories and interviews, create a unique and important non-fiction story. With restraint, Thompson folds in scholarly research and definitions only where they are needed to provide perspective with the greatest economy of words. It is never academic, but the depth of thought takes the story past the superficial and poses questions of importance to the profession of landscape architecture and to Americans.

Lisa Horne, ASLA, is a project leader at Studio Outside in Dallas, Texas, and incoming chair of the ASLA Professional Practice Network. She may be reached at lhorne (at) studiooutside.us. Thank you, Lisa, for this excellent book review!

Thank you to Pennsylvania State University Press for providing a review copy.

And thank you, Bill Thompson, for such a thoughtful, meaningful book.

Photo courtesy of the National Park Service

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Remembering Stephen Kellert

December 2nd, 2016
A yellow-rumped warbler

A yellow-rumped warbler

Stephen R. Kellert, “biophilia” scholar and lifelong champion of the natural world, died on Sunday, November 27, 2016 of multiple myeloma. I learned of his death yesterday from a lovely post by Richard Louv and The Children and Nature Network.

I met Steve on a chilly spring day in April, 2012 at his home in New Haven, Connecticut. He greeted me warmly and led me to the living room/study, where the proofs from his latest manuscript, Birthright: People and Nature in the Modern World, lay on the desk to my right. I wish I had a greater memory for visual details. What color was the sofa I sat on? Did he sit in a wooden chair, or was it upholstered? What were some of the books that lined the wall behind him? He wore wide-wale corduroy trousers, which struck me as perfectly professorial, but was he really wearing a tweed blazer with elbow patches, or is that just my imagination? He was, after all, the Tweedy Ordway Professor Emeritus of Social Ecology and Senior Research Scholar at the Yale University School of Forestry and Environmental Studies.

What I remember most clearly was the picture window, maybe 6 feet tall by 10 feet wide, that took up most of the back living room wall. Through it we could see his wild yard, and beyond that the Mill River and East Rock, a long, tall cliff that rises dramatically from the riverbank. We talked for an hour or so, about his new book, and another co-edited book that had just come out–Companions in Wonder. And about the role of the sacred, and spirituality, in people’s interaction with nature and how difficult that can be for academics to address. I asked him how he was able to do it, and he smiled mischievously: At this point in his career, he could do what he wanted. He expressed his concerns about “evidence-based design” and the danger of reducing things like nature connection and the benefits of time outdoors to mere numbers. In science, including EBD, people have a low tolerance for ambiguity, which may deprive us of the delicious complexity that nature, and our relationship to it, has to offer.

And then something caught his eye and he leaped from his chair to the window for a better view of the first yellow-rumped warbler of the season. He explained, while reaching for binoculars, that their migration had just begun and it was his first sighting of the year. He offered me the binoculars and guided my eyes to the small black and white bird with flashes of bright yellow on its head, wings, and, yes, rump. We settled back down to talk but more warblers kept distracting him. When he apologized, I refused to accept–Are you kidding, I said, what better way to know Stephen R. Kellert than to share in the delight of nature in that moment in his own back yard?

If you haven’t yet read anything by this giant in our field, you might start with Birthright. I also strongly recommend one of the “bibles,” The Biophilia Hypothesis, which he co-edited with E. O. Wilson. And read Wilson’s Biophilia while you’re at it. Kellert’s film, Biophilic Design, is excellent. And the list goes on and on. While it’s tempting to say “a light has gone out” or something to that effect, I really don’t think it’s true in Steve’s case. His teaching, writing, and advocacy still shines brightly, and I know it always will.

Please honor Steve’s commitment to the natural world by supporting The Wilderness Society, 1615 M Street, Washington DC 20036.

Photo from http://www.biologicalcapital.com/board/dr-stephen-r-kellert/

Photo from http://www.biologicalcapital.com/board/dr-stephen-r-kellert/

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What is a Healing Garden?

September 11th, 2016
Legacy Meridian

Healing Garden at Legacy Meridian Park Medical Cntr, designed by Brian Bainnson. Photo by Naomi Sachs

My colleague, Dak Kopec, asked me to write a piece on healing gardens for his forthcoming book,  Environmental Psychology for Design, and he has graciously given permission to share it with you here on the TLN Blog. Dak is Director of Design for Human Health at Boston Architectural College and has written many books and other publications on the role of the environment in human health. Thank you, Dak!

Griffin Healing Garden

Healing Garden at The Center for Cancer Care at Griffin Hospital. Photo by Naomi Sachs

What is a “healing garden”?

A “healing garden” is a garden or landscape designed for a specific population, place, and intended positive health outcome. The garden’s design (physical aspects) and programming (activities that take place there) are informed by research. The majority of healing gardens, also referred to as “restorative gardens” and “healthcare gardens” are in healthcare facilities including general acute care hospitals, outpatient clinics, assisted living and skilled nursing facilities, mental and behavioral health facilities, hospices, and specialty facilities such as rehabilitation, pediatric, and cancer hospitals and clinics. Garden users include patients or residents, visitors, and staff. Positive outcomes, including stress reduction, are derived through both passive and active nature connection and can take place indoors (via indoor plants, or from viewing nature through a window) and outdoors. A “rehabilitation garden,” “therapeutic garden,” or “enabling garden” is a garden where physical, occupational, horticultural, and other therapies take place. A “restorative landscape” or “landscape for health” is any landscape—wild or designed, large or small—that facilitates human health and well-being (Sachs, 2016).

TIRR Memorial Hermann

Planter with patient-painted tiles, TIRR Memorial Hermann. Photo by Naomi Sachs

Why is access to nature important?

Access to nature promotes health through reduction in stress, depression, myopia, pain, fatigue, aggression, impulsivity, and symptoms of Attention Deficit Hyperactivity Disorder (ADHD); and improvement in immune function, bone strength, wound healing, cognition, concentration, emotional resilience, empathy, vitality, relaxation, mood, and satisfaction (Cooper Marcus & Sachs, 2014; Kuo, 2015). Why is nature good for us? Part of the answer can found in the theory of biophilia, “the innately emotional affiliation of human beings to other living organisms” (Kellert & Wilson, 1993, p. 31). Stephen and Rachel Kaplan’s Attention Restoration Theory (1995) is based on the concept that “positive distraction” and “soft fascination” through nature engagement lead to mental and cognitive restoration from the stress caused by “directed attention.” More recent research has identified enhanced immune functioning as a potential “central pathway” in explaining the connection between nature contact and positive health outcomes. Nature, in hospitals and elsewhere, plays a salutogenic role in both disease prevention and health promotion (Kuo, 2015).

Healing Garden at Houston Hospice.

Healing Garden at Houston Hospice. Photo by Naomi Sachs

What elements are important in healing gardens?

Safety, the perception and safety, and comfort are all essential in healthcare gardens. Good design and proper maintenance can address challenges such as climatic extremes, inclement weather, pollen, and harmful bacteria and insects. For example, a choice of sun and shade enables users to be outside throughout the day. Covered seating areas, especially at the garden entrance, allow even the frailest of users to venture out when the weather is not ideal. Gardens should be designed so that even when they are not physically accessible, they can be viewed from indoors and are a pleasure to see in all four seasons. According to Roger Ulrich’s Theory of Supportive Garden Design (1999), healing gardens should provide 1) nature engagement (plants, animals, water, fresh air), 2) a sense of control (for example, doorways that are easily navigable, and areas where people can find privacy), 3) opportunities for social support, and 4) opportunities for movement and exercise. While it may seem obvious that nature should be present in a healing garden, examples of nature-poor healthcare “gardens” abound. Stakeholders must work together to maximize the natural, biophilic elements that facilitate the best possible outcomes for all users.

Smilow Cancer Center

Betty Ruth and Milton B. Hollander Healing Garden, Smilow Cancer Hospital. Designer: Towers Golde. Photo by Naomi Sachs

References

Cooper Marcus, C., & Sachs, N. A. (2014). Therapeutic landscapes: An evidence-based approach to designing healing gardens and restorative outdoor spaces. Hoboken, NJ: John Wiley and Sons.

Kaplan, S. (1995). The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15, 169–82.

Kellert, S. R., & Wilson, E. O. (1993). The biophilia hypothesis. Washington, DC: Island Press.

Kuo, M. (2015). How might contact with nature promote human health? Promising mechanisms and a possible central pathway. Frontiers in Psychology, 6(1093).

Sachs, N. A. (2016). Gardens/Overview. Therapeutic Landscapes Network website. Retrieved from http://www.healinglandscapes.org/gardens.

Ulrich, R. S. (1999). Effects of gardens on health outcomes: Theory and research. In Cooper Marcus, C. & Barnes, M. (Eds.), Healing gardens: Therapeutic benefits and design recommendations (27–86). New York: John Wiley and Sons.

Book citation: Sachs, N. A. (in Press). In D. Kopec (author). Environmental psychology for design, 3rd Edition. New York: Fairchild Books.

 

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‘Therapeutic Gardens’ – Book review by Lisa Horne

September 8th, 2016

Collaborative and Compassionate Design – Guest post & book review by Lisa Horne of Therapeutic Gardens: Design for Healing Spaces

Photo by Lisa Horne

Therapeutic gardens come in many different forms… Image Source: Lisa Horne

In Therapeutic Gardens: Design for Healing Spaces, Daniel Winterbottom and Amy Wagenfeld expand the conversation on therapeutic gardens and broaden the definition to many places beyond medical facilities and hospitals. This leads to the appropriate question of whether all gardens are therapeutic, which is answered generally with this quote from Robert Rodale: “Gardens are where people and the land come together in the most inspiring way.”1 This book, which recently won the 2016 Place Book Award from the Environmental Design Research Association, recognizes its place in a growing body of literature and adds value to the discussion in its interdisciplinary nature and its challenge to the concept that therapeutic gardens are limited to certain places. As an occupational therapist, Amy Wagenfeld infuses the text with an empathy and warmth not often found in design books.

The book can be divided into three sections of overview, therapeutic garden typologies, and maintenance. The first two chapters give a general overview. “Foundations” looks at history, theory, research, and applications from the perspective of an occupational therapist. “Collaborative Design” discusses the design process with a case study of a courtyard designed for Japanese Americans at a senior care facility and identifies various design elements for therapeutic gardens. The typology chapters each have a broad topic such as movement, solace, or learning and examine specific kinds of gardens within that topic such as gardens for children with cancer or children with obesity. Each kind is described fully and followed with a brief section of specific design considerations. Each typological chapter has at least one “Closer Look” section, a case study that illustrates one of the kinds of gardens. Most case studies have plans.

Two prevailing and interrelated ideas of collaborative design and compassionate design weave through the book. Collaborative design is not a new concept. It is often acknowledged, but less frequently practiced in the profession. Collaboration can take a back seat for fear that engaging users could redirect the project inappropriately. Where this particular book adds value is its fearless and detailed narrative of what collaboration actually looks like. It implies that landscape architects can creatively design ways to overcome barriers such as language, culture, and socioeconomic status to include more challenged groups. One specific example was a project in Guatemala City in which there was a language barrier. The participants tagged images in books or created collages and models in clay. The compassionate argument is also imbued through the text. There is an emphasis on universal design principles and sensitivity to the nuances of impairment, disability, and handicap. It is not just semantics, but rather is intended to place the person at the center of the design. The closing paragraph of the “Afterword” emphasizes this concept by stating that great design is both responsive and compassionate.

Perhaps the most distinctive element of the book is its warmth of tone. There is elegance to the text. The introductory chapters carry the reader through complex intellectual territory complete with references to phenomenology and the more nuanced explanations of definitions with finesse. The photographs are up to date, high quality, and a visual delight. As a picture book for ideas, it delivers. The plan diagrams lucidly communicate the central point with no additional embellishment. More technical readers may miss footnotes or endnotes to follow up on some of the more provocative points in the text although there is a complete list of references at the end of the book.

Photo by Lisa Horne

…And different sizes. Image Source: Lisa Horne

Although the intended audience is not explicitly stated, we have several clues from the text. Landscape architects are mentioned in the final paragraph of the “Afterword.” The second chapter gives an overview of the design process, which would have merit for students of landscape architecture. The book will be on my list of go-to books for visual inspiration, but it is not as deeply technical as some other related books. For example, Therapeutic Landscapes by Clare Cooper Marcus and Naomi Sachs goes into the more technical aspects of meeting the Health Insurance Portability and Accountability Act (HIPAA) requirements for therapeutic gardens in medical settings, which are not mentioned here.

This book is a rare piece of interdisciplinary collaboration between a landscape architect and occupational therapist and functions as both a source of inspiration for students and practicing landscape architects and a manifesto for compassionate, user-centered design. It adds a valuable voice to an ongoing conversation in our profession.

Photo by Lisa Horne

Interdisciplinary collaboration inspires design. Image Source: Lisa Horne

1 Winterbottom, Daniel, and Amy Wagenfeld. Therapeutic Gardens: Design for Healing Spaces. Portland, OR: Timber Press, 2015.

Note: Timber Press provided a review copy for the writing this book review.

Lisa Horne, ASLA, is a project director at RVi in Dallas, Texas, and past co-chair of the ASLA Children’s Outdoor Environment Professional Practice Network. She may be reached at lhorne (at) rviplanning.com. Many thanks, Lisa, for another terrific book review!

 

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