Healing Spaces

Esther M. Sternberg MD

• Publisher: Belknap Press
• Year: 2010
• ISBN:
  9780674256835
• Topic: Medicine
• Subtopic: Alternative & Complementary Medicine

"Esther Sternberg is a rare writer—a physician who healed herself…With her scientific expertise and crystal clear prose, she illuminates how intimately the brain and the immune system talk to each other, and how we can use place and space, sunlight and music, to reboot our brains and move from illness to health."—Gail Sheehy, author of Passages Does the world make you sick? If the distractions and distortions around you, the jarring colors and sounds, could shake up the healing chemistry of your mind, might your surroundings also have the power to heal you? This is the question Esther Sternberg explores in Healing Spaces, a look at the marvelously rich nexus of mind and body, perception and place.Sternberg immerses us in the discoveries that have revealed a complicated working relationship between the senses, the emotions, and the immune system. First among these is the story of the researcher who, in the 1980s, found that hospital patients with a view of nature healed faster than those without. How could a pleasant view speed healing? The author pursues this question through a series of places and situations that explore the neurobiology of the senses. The book shows how a Disney theme park or a Frank Gehry concert hall, a labyrinth or a garden can trigger or reduce stress, induce anxiety or instill peace.If our senses can lead us to a "place of healing, " it is no surprise that our place in nature is of critical importance in Sternberg's account. The health of the environment is closely linked to personal health. The discoveries this book describes point to possibilities for designing hospitals, communities, and neighborhoods that promote healing and health for all.

1

HEALING PLACES

There is a turning point in the course of healing when you go from the dark side to the light, when your interest in the world revives and when despair gives way to hope. As you lie in bed, you suddenly notice the dappled sunlight on the blinds and no longer turn your head and shield your eyes. You become aware of birdsong outside the window and the soothing whir of the ventilation system down the hall. You no longer dread the effort needed to get up, but take your first cautious steps, like a child, to explore the newfound space around you. The smell of food does not bring on waves of nausea or revulsion, but triggers hunger and a desire to eat. The bed sheets feel cool and soothing—their touch no longer sends shivers through you, like chalk-squeak on a blackboard. Instead of shrinking from others, you welcome the chit-chat of the nurse who enters the room.

This is the point when the destructive forces of illness give way to healing. In every sense, it is a turning point—a turning of your mind’s awareness from a focus on your inner self to a focus on the outer world. Physicians and nurses know that a patient’s sudden interest in external things is the first sign that healing has begun. But do our surroundings, in turn, have an effect on us? Can the spaces around us help us to heal? Can we design places so as to enhance their healing properties? And if we ignore the qualities of physical context, could we inadvertently slow the healing process and make illness worse?

The idea that physical space might contribute to healing does, it turns out, have a scientific basis. The first study to tackle this question, published in Science magazine in 1984, showed that when hospital rooms have windows looking out on the natural world, patients heal more rapidly.

The sun was setting over Buzzard’s Bay as the conference participants gathered for the evening. The sky glowed so brilliantly that even the white wine in their plastic cups seemed to catch fire.

“Look at that. That’s got to have a healing effect!” Roger Ulrich waved his hand over the scene—dozens of sailboats moored in a still and fiery sea. He was standing on a bluff overlooking the bay at the southern end of Cape Cod, in front of a rambling gray saltbox-style building: the retreat and conference center of the National Academy of Sciences. It was here in August 2002, near the old whaling village of Woods Hole, Massachusetts, that John Eberhard, director of research at the American Institute of Architects (AIA), was hosting a collaborative workshop for scientists and architects, to explore the interface between architecture and neuroscience. It was the first workshop of what would become the Academy of Neuroscience for Architecture.

Ulrich’s relaxed demeanor and boyish face belied the fact that he was a noted authority on the subject. He wasn’t making an offhand remark or a haphazard guess. It was he who had performed the landmark 1984 study showing that window views could affect healing. He was responding to a question about what had inspired him to conduct that study.

“It just seemed like common sense,” he said. “And the patients were already there, already being monitored for all sorts of things—heart rate, EKG, blood pressure, temperature—everything you could imagine. So we used those numbers to measure whether or not the windows had an effect on healing. We did it. And it worked.”

He had examined the hospital records of patients who had undergone gall bladder surgery in a suburban Pennsylvania hospital during the period 1972–1981. He’d chosen forty-six patients, thirty women and sixteen men, whose beds were near windows that overlooked either a grove of trees or a brick wall. Twenty-three beds had views of nature and twenty-three did not.

Ulrich had recorded each patient’s vital signs and other indicators of health, including dosages and types of pain medication and length of hospital stays. He’d found that patients whose beds were located beside windows with views of a small stand of trees left the hospital almost a full day sooner than those with views of a brick wall. Not only that, but the patients with nature views required fewer doses of moderate and strong pain medication. The results were dramatic and statistically significant. Ulrich had selected only forty-six patients to study because he was controlling for variables that could affect recovery, such as age, sex, whether the patients were smokers, the nature of their previous hospitalizations, the year of their surgery, even the floor their room was on. Each pair of patients—view of nature, view of brick wall—had been cared for by the same nurses, so differences in nursing care could not account for the differences in speed of recovery. Even doubters had to sit up and take notice.

The notion that nature was important to healing had been around for thousands of years—going back to classical times, when temples to Asclepius, the Greek god of healing, were built far from towns, high up on hilltops overlooking the sea. But by the late twentieth century, state-of-the-art hospitals were generally designed to accommodate state-of-the-art equipment. The more scanners and X-ray devices a hospital had, the more electroencephalograms and electrocardiograms it conducted, and the more sophisticated its biochemical blood and urine tests, the more advanced its care was considered to be. Often, the hospital’s physical space seemed meant to optimize care of the equipment rather than care of the patients. In the early 1970s, one could still find hospitals where the only department that was air-conditioned was the Radiology Department, because the delicate equipment could not tolerate the summer heat. As reliance on and awe of medical technology increased in the mid-twentieth century, the comfort of the patients was somehow pushed aside and their surroundings were often ignored. Hospital planners assumed that patients could adapt to the needs of technology, rather than the other way around. When did this happen? When did the focus change from the patients to the disease, from healing to diagnosing and treating?

In the nineteenth century, hospitals were built with large windows and even skylights. Although this was done for the sake of visibility, in the days before powerful electric-light sources had been perfected, it was also done to help patients heal. Clinics and hospitals were designed to take maximum advantage of available sunlight, with large windows facing south and a solarium at the end of each ward. Even the word “solarium,” meaning a room where patients could sit and absorb the healthful rays of natural light, is derived from sol, the Latin word for “sun.”

In the late nineteenth and early twentieth centuries, the notion that sunlight could heal was very much in vogue. The great scourges in those days, before the development of antibiotics, were infectious diseases, especially tuberculosis. Sunlight and open windows were thought to be among the most effective means of purifying the air. In 1860, Florence Nightingale wrote that darkened rooms were harmful and sunlit rooms healthful; large, airy, bright rooms were the hallmark of what came to be known as a “Florence Nightingale” hospital ward. In 1877, a paper was presented to the Royal Society in London showing that sunlight could kill bacteria. In 1903, Dr. Auguste Rollier opened a sunlight clinic in the Swiss Alps. This may have been an inspiration for Modernist architects of the 1920s and 1930s, who designed homes and hospitals to take advantage of the sun.

Roger Ulrich’s 1984 study grew out of this tradition, but had an added twist. He wanted to test whether views of nature were calming, and whether, by reducing the stress of hospitalization, they could in turn improve health. His ideas were based on a long tradition in modern architecture that posited a connection between architecture, health, and nature. Prairie School architects like Frank Lloyd Wright and Modernists such as Richard Neutra and Alvar Aalto designed buildings that appeared to grow out of their natural settings. In Neutra’s structures, the glass walls seemed to melt away, allowing the indoor space to merge, almost seamlessly, with the outdoors.

Both Aalto and Neutra were explicit about the health benefits of well-planned architecture and about the importance of nature and natural views in health and healing. This concept may have had its roots in the tuberculosis sanatoriums of the nineteenth and early twentieth centuries, in the days before antibiotics. Patients with TB were sent to hospitals high in the mountains, in the hopes that the air at those altitudes would snuff out the infection. A perhaps unintended advantage was that these hospitals were all located in beautiful and isolated natural settings.

Indeed, the TB sanatorium designed by Alvar Aalto, built in 1929–1932 in the town of Paimio in his native Finland, became the standard for all later hospitals. It featured a patients’ wing with light-filled rooms that faced south and overlooked a pine forest. The resting lounge was also bright, with a wall of tall windows looking out on forest views. Aalto was careful to stipulate that the surroundings be pleasant and tranquil. He even designed the furniture with the patients’ comfort in mind, slanting the back of his sleek, laminated-wood “Paimio” chairs so as to ease the patients’ breathing.

Although Richard Neutra admired and emulated the way Frank Lloyd Wright embedded buildings in natural surroundings, he went beyond Wright, using steel and concrete and walls of glass to create structures that had a much lighter and airier feel and that blended indoors with outdoors. His Lovell “Health House” in Los Angeles—designed for the physician and Los Angeles Times health-column writer Philip Lovell and his wife, Lea—fit with the couple’s convictions about health. It had views of nature on all sides.

These Modernist architects based their work on theories of the interface between design and health, but Roger Ulrich was the first to actually measure the effects of patients’ surroundings on the healing process. The question at the Woods Hole Conference was not so much whether windows and nature views could heal, but how the healing mechanism operated. What brain pathways did windows and their views of nature activate? And how might these affect the immune system and its healing process?

John Eberhard, in his late seventies at the time of the conference, was a complicated man. He had held many important posts, including the chair of the Department of Architecture at Carnegie Mellon University. He had come up through the ranks in an era when architecture was almost exclusively the purview of white Protestant men. It had been a time when even the now world-famous architect Frank Gehry was persuaded by his wife to change his birth name, Goldberg, in order to get ahead. Perhaps because of his life experience, Eberhard wore his authority on his sleeve. He was a man used to wielding power and getting results, fast, and he sometimes pushed underlings almost to the point of tears to get things done. But under this tough exterior he had a softer side. He could come close to tears when talking about his legacy and his vision for his beloved field of architecture. He was also a talented artist who could execute quick, detailed sketches of buildings. And he read voraciously in pursuit of his interests, especially, at this juncture, in the field of neuroscience.

In 2002, Eberhard’s title as director of research at the American Institute of Architects was a bit of an oxymoron, since the AIA was at times ambivalent about its role in research. Its primary mission is to set and maintain the highest standards in architecture, not to oversee or support research. But the AIA governance structure charged its CEO with setting programmatic priorities for its “knowledge communities,” including architecture of hospitals, churches, schools, technology, and building science. Norman Koonce, a gracious, erudite gentleman from Lousiana, was then CEO and had long been interested in how architecture could enrich the human experience. In fact, he had recruited Eberhard in part with this goal in mind. The interface between architecture and neuroscience fit perfectly with these goals, and Koonce gladly supported exploring how the fields could inform one another. The workshop at Woods Hole brought together architects, neuroscientists, and psychologists whose expertise spanned the areas of stress research, visual perception, and environmental psychology.

If they could understand how physical surroundings affect emotions and how emotional responses to architecture affect health, then people’s health could be taken into account in the design of buildings. Perhaps architects might even have some objective ammunition when trying to convince clients to spend a little more on larger windows and natural settings. Perhaps “green” design would turn out to be as beneficial to individuals’ health as it is to the planet’s health.

In his 1954 book Survival through Design, Richard Neutra said: “A workable understanding of how our psychosomatic organism ticks, information on sensory clues which wind its gorgeous clockwork or switch it this way or that, undoubtedly will someday belong in the designer’s mental tool chest.” In those days, the tools of neuroscience and immunology had not yet advanced to the point where they could be included in that tool chest. Today they have. And this is what the Woods Hole conference was all about: how to use those tools to inform the fields of neuroscience and architecture, and in turn promote healing.

The decision to include environmental psychologists like Roger Ulrich represented something of a rapprochement among the fields represented at the workshop. For decades, psychologists had been studying the effects of physical space on various aspects of mood, problem solving, and productivity. But as often happened in the scientific community, their methods, based in large part on participants’ responses to questionnaires, were viewed by more biologically oriented investigators as “soft science.” For their part, the architects had long known about these findings and felt there was nothing new to be learned from this approach. Nonetheless, the workshop provided a forum for a rich exchange of ideas—a chance for each field to contribute to the exploration of how the brain responds to built space, and how physical context in turn could foster good health, productive energy, and creative thought.

At Woods Hole, after a series of introductory lectures, the conferees broke up into working groups, each co-chaired by a neuroscientist and an architect. Roger Ulrich chaired the “Windows” group. These smaller sessions were meant for brain-storming. The “Windows” group would use the time to speculate freely about how windows might promote healing, and also to come up with ideas about what each discipline could measure. Why and how could window views affect healing? Was it because they provided more natural light? More airflow? Access to the sounds and smells of nature? Awareness of the rhythms of day and night? Did they simply distract patients from the monotony of days trapped in bed?

The architects in the group went first. They could measure light intensity, wavelength, and color; temperature; airflow; and levels of activity in the scene being viewed. They went through the list of all the qualities that one could measure with sophisticated instruments in minute detail, to quantify every imaginable characteristic of physical space. This list would make it possible to design a study where researchers could measure and control these variables, in order to work out which factor or factors might explain the windows’ effects.

The neuroscientists went next. They could monitor areas in the brain that became active when the patient was looking at a scene. They could measure physiological responses such as stress and relaxation. They could measure stress hormones in saliva, and changes in heart-rate variability and breathing. And they could measure general indicators of health such as immune responses, dosages of pain medications prescribed, and length of hospital stays.

The group concluded that by combining the most advanced tools of neuroscience, architecture, and engineering, one could dissect and measure each feature of a patient’s physical environment, and the way each of those stimuli was received by the patient’s brain and body. Researchers might then be able to identify elements in the physical environment that help people heal.

But could all this really be done? Would it be possible to isolate the single or several factors in the physical environment that contribute to healing? Or would it turn out to be something more—something intangible—that makes some places heal and others harm? Perhaps the most important thing a window does is provide a portal—an escape from the frightening, painful reality of disease, or a way of accessing memories of a better time and place. Maybe windows exert their effect by allowing a patient to step into a space of meditation—a reverie that brings not just distraction but relief. And relief could bring healing, through all those beneficial chemicals that flow from the brain through the body and change illness into wellness. Any or all of these hypotheses were possible, the workshop concluded. Research would confirm which ones were valid.

The conferees at Woods Hole were by no means the only ones advocating a collaboration between neuroscience and architecture to answer these questions. A new field does not emerge solely from the efforts of a few individuals, though it certainly needs individuals with vision, courage, perseverance, and drive to build and sustain it. A new field emerges after years, often decades, of accumulated knowledge, which at some point takes off exponentially. But even this often stems from thousands of years of implicit knowledge and questions that have been circulating in the general culture.

The idea that built space may affect health could not be investigated in scientific terms without the late twentieth-century advances which established that connections between the brain and the immune system are essential to maintaining health. Implicit in an understanding of the mind-body connection is an assumption that physical places that set the mind at ease can contribute to well-being, and those that trouble the emotions might foster illness. It would take significant advances—elucidating how the brain perceives physical space, how we remember and navigate the world around us, and how all this can affect emotions—to lay the groundwork for a new field linking those who design physical space with those who seek to understand the brain’s responses to it. Collaborative intellectual endeavors between neuroscientists and architects are not new. From the days when scientists first began to study the brain, architects played a prominent role in attempts to map the brain and its mysterious structures.

Some four hundred stone steps lead up through the dome of St. Paul’s Cathedral, built four centuries ago in London by the architect Sir Christopher Wren. Climb those steps and you will come to a narrow balcony ringing the dome’s interior, halfway to the top. It is called the Whispering Gallery because two people can stand at opposite sides of the enormous space and carry on a conversation in whispers, every word clearly intelligible. Children who visit the dome delight in trying out the acoustics.

But Wren didn’t build St. Paul’s so that people could play games. He built it, and many other churches in the vicinity—a “flock of Wrens,” Londoners call them—to replace structures destroyed in the Great Fire of 1666. If you wander into the cathedral when the choir is practicing, you might hear the crystalline voice of a countertenor wafting up past the Whispering Gallery to the very top of the dome—a voice so clear that no matter where you stand, it seems the singer is standing next to you, and this with no microphones or amplification. You feel a sense of awe and peace in that vast space, exactly as Wren had intended when he built the dome.

Walk west from St. Paul’s, past the staid stone buildings that house the courts and legal offices of Temple Bar, and soon you come to Oxford Street’s bustling shopping district. Your gaze is attracted by windows filled with goods from all over the world. Keep walking down Oxford Street past Oxford Circus, make a little jog to Cavendish Square, and you reach the Royal Society of Medicine, part of the Royal Society established around the same time that Wren built his cathedral. One of the society’s founders was Sir Thomas Willis, the anatomist whose intricate drawings of the brain, published in 166...