INSTITUTIONAL ENVIRONMENTS

Fear, isolation, and a sense of numbing helplessness characterize the nursing home, the mental hospital and other institutional experiences for the majority of inmates. To enter a hospital, especially a mental hospital or a nursing home, either as a visitor or a patient, is to encounter an environment that has no equal in barrenness anywhere in our culture except for the prisoner's cell.

These environments may be described as dis-integrated or degraded because they lack wholeness; they are incomplete. Because the ordinary everyday settings for behavior are missing, they cannot adequately support the great range of human activities and behaviors that are associated with everyday life and particularly with the recovery process. Most institutions force inmates to ‘kill time’ without purpose. More typically and destructively, institutional environments may further impair the patients' faith in their own competence to take care of themselves and live normal independent lives. Prolonged institutionalization or hospitalization, especially in a mental hospital, nursing home, or prison may seriously impair the inmate’s mental health, as individual’s responsibilities and social behaviors fall away.

Psychiatry and psychology in particular, and medicine in general, all lack a clear vision or theory of mental health and ‘wellness’, as distinct from illness, that could inform and enrich the lives of patients in their care. Since the earliest records of institutional mental health treatment there have been relatively few reform revolutions during which the quality of the patients' experience, their environment, and their care were given enriching humane attention.

If we narrow our focus to prison systems, jails, and military prisons, environments become punishingly, dangerously, dysfunctional and ‘crazy-making’, bordering unintentionally upon mental and emotional torture. (This second or third-order unintentionally is responsible for a great deal of human suffering that results from the insufficiently examined wish or will to do ‘good’.)

Without an understanding of what constitutes psychological health, institutional environments designed to healthful specification simply cannot be conceived of, programmed, designed, or built. Patients and prisoners must therefore live within what remains— in environments that at best may allow recovery from physiological trauma, but that give the spirit and psyche further injury but no succor.

In our country we have imprisoned and later released into society so many (mostly young males) that the impact of these environments is felt everywhere, but most tragically in the black urban areas. We must now understand that our cultural environment is shaped by the worst environments conceivable—those settings society offers-up to prisoners and mentally ill persons. Every neighborhood throughout the nation experiences the negative impact of long-term institutionalization in dangerous and dehumanizing environments upon our most vulnerable people. In some sense, in our houses and on the streets, we are all in prison.

In every city and throughout the countryside there are countless forgotten and underserved families and individuals who suffer from to the after-effects of imprisonment or institutionalization in dehumanizing facilities. If we look at crime statistics it becomes clear that we do great damage to inmates and to ourselves by what we do to them in ‘treatment’ or ‘rehabilitation’. This damage outweighs any problems our neighbors may have caused within our communities before their imprisonment or institutionalization. For many decades these large-scale failures in health-care and penal-care environmental policy have been accumulating, contributing to the amplification and propagation of illness, trauma and crime to now nearly epidemic levels. We live within the fire of a rapidly expanding culture of rage, revenge and violence.

How can architecture contribute to or overcome these troubles?

What is missing in our contemporary, often esthetically elegant hospital structures? From the patients' perspective, the impact of these hospitals is only slightly different from their counterparts of 40 or 50 years ago when, as I can attest from personal observation, they were horrifying. Most such environments still lack perceptual and behavioral richness and meaning. In these places, the devils are in the lack of details.

Most patients at some time during the course of their recovery will wish to engage in behaviors that these barren environments prevent. The physical, architectural environment is the matrix and structural support for behavior and health. Richly detailed environments provide the attachment points for meaning, behavior and social interaction that we all need all the time. These are vital functions of the architectural environment. We cannot have healthy sleep without a place in a room where we may lie down safely. Private conversation cannot be heard next to a loud TV set. The corridor is not a good place to cry. Living-rooms in most homes are detailed in ways that distinguish them from being misinterpreted as bathrooms. For instance, the living-room walls and floors would not be finished with the same tiles as the bathroom. Ordinarily, the functions and uses of rooms are distinguished by their details.

This is not true in many institutional settings where behavioral cues and supports frequently lead to confusion. This is not to claim that mental illness is caused by bad wallpaper. (one may wonder). But for a mentally-ill person trying to make sense of his own confused conception of the world, a confused world can make recovery more difficult.

How do people use physical perceived sensory richness in an architectural environment? How do people translate architectural stuff into a rich sense of being in a meaningful place? How do spaces become recognizable as places? How does good hospitable architecture contribute to healthy human experience? What meanings do people derive from, or impart into the physical places where they live, and how do we do that?

We need architectural places that are rich in familiar and useful detail that contain the stuff we can call our own, or that we can use or participate within, in other words stuff that is appropriate to our everyday life needs; stuff that we know how to use, stuff we are allowed to use. In a total institution we must have great richness, diversified enough to support every healthful behavior for the time we live there. A complete archetypal environment can support a complete life, but to do so it must have all the necessary components, tools, behavior-places and furnishings that humans have been accustomed to use and require in the culture where they were born. The stripped-down environment of many institutional settings is actually dangerous to mental functioning; it is altogether too sterile. It can drive one crazy.

There is a tension between meaning in the environment and sensory sterility.

We live our everyday lives mostly unaware of the environmental support system of our buildings. That can only be true if our buildings and places are furnished appropriately and with appropriate complexity. We manage not to be confused by all this complex incoming data and phenomena because our brains have the ability to selectively attend only to those parts of the environment that are of particular momentary interest—the parts that mean something to us right now. In searching through the shelves of a library stack, we do not read the title of every book that our eyes scan, instead we may pick up only the first letters of the author's name, or the file numbers. We may remember what the book looked like and take an interest in the colors of the book jackets as we pass. We expend a small yet continuous amount of energy filtering out the massively irrelevant remainder of information that reaches our senses from all sides and from every shelf. Nonetheless, even though we sift through it and use only small parts of it at any time, the holistic richness of the environment is of crucial importance to us and to our mental health. We are a curious, stimulus hungry species. Our eyes, minds, hands, will idly fiddle with random bits of the environment, seemingly without motivation or conscious intent. Our brains need to do this work.

As the focus of our interests and activities changes, features of the environmental that were previously suppressed become more interesting and we now notice them. We are able to consign some of what we experience to the category signal, while always keeping a larger part in the background as noise. But, in the course of a day even within the same room, we are likely to reassign some stimuli from the noise into the signal category or the reverse. When reading the newspaper we ignore the doughnuts on the table. When we are hungry we eat the doughnuts and ignore the newspaper

Sensory deprivation studies have suggested that when these opportunities to "fiddle" are withdrawn, our senses begin to shut down, and focus inward for their stimulus needs. Hallucinations are the sequel to this process, and they are almost unanimously reported by the subjects who participate in sense-deprivation experiments. Apparently we require a continuous array of signals and stimuli to keep us turned on and tuned in and for our mental focus to be directed outward keeping our interest and alertness fully charged. Without this information array, we lose our mental balance and fall inward and find something to focus on from our own noisy mental archives.

I should like to offer an hypothesis. It seems that the mind resembles a news agency. When things are normal and information rich; we edit and register to awareness and "print" only what we feel is relevant and fit to be aware of. We make both conscious and subconscious judgments and strategies in editing. If the environment is barren (as when we are imprisoned or institutionalized), we become less discrimi-nating and begin to search for and to ‘print’ anything we can discover or imagine. Eventually we become completely unable to edit the dull from the dullest and will accept any thing that moves as interesting news and obsess about it. In an information blackout, anything seems like news. If, in this sensory drought, the stimulus originates as noise from within our own brains we may, if the situation is prolonged, become unable to detect the solipsism, and descend into a feedback cycle of obsessing about our own neuroses and anxieties believing them to be real, as our thoughts and fears replace all that used to exist. If the analogy is correct, or nearly so, then a sterile environment that starves the senses and the hungry mind is not appropriate for the mentally ill. Architecturally elegant, spartan, hazard-free, ‘suicide-safe’ settings are not safe, they amount to a subtle form of emotional and mental torture. The mentally ill and the imprisoned have enough troubles.

Some workers have suggested, and I think misguidedly so, that when we are ill we need an especially enriched prosthetic sensory world, but the mentally ill need what we all need—only an ordinary and complete world. Their world should resemble the world they recognize as familiar when they are in their healthiest periods. How else will they be able to tune themselves back into living the kind of life they would like to live? How, indeed, will they know if they have arrived at better mental health unless things look and feel as they did before they slid into their ‘bad trip’? Architecture, outside and inside, particularly institutional architecture, is, to borrow a term from computer technology, the GUI (Graphic User Interface) of the real world. And it better be one we know how to use or we will lose access to our life’s data.

Consider how the environment takes on meaning for people. A first and obvious point is that meaning is an idiosyncratic thing and no two individuals will derive exactly the same meaning, or attach the same importance to any particular aspect of the environment however much they may agree upon and share. Secondly, meaning does not inhere in the environment—it is in our heads. The environment is just stuff, neutral, free of import, omen and interpretation—but a well designed environment does provide conventions that may arrange that stuff in ways that mesh with our expectations and learned behaviors. As representatives of our culture we bring all that baggage into our buildings as experience, learning, conditioning, and so on. Not only do we lug baggage, but we come quite heavily burdened, and are always looking for a place to rest our load. We seek places of psychic and emotional attachment safe within the physical world of walls and chairs in which we can feel secure and at home. We are determined to anchor ourselves into our settings by these affections as firmly as limpets; my place at table, my clothes closet, my bed and pillow.

But the process by which we identify and select our own meaningful points of attachment to architectural places is by no means random or unique to each of us. It is mediated by processes that we share in our commonly held from our learned association pat-terns and from our cultural conditioning. Were it not for these processes, we as designers, administrators, and caregivers could never hold a hope of arranging things so that a population about which we have only general knowledge could have a reasonable chance of digging in and becoming comfortable. Because we are able to gen-eralize about a subculture to some extent; because we can know how its people arrange their lives in their environments, we are able to specify features of their architecture which will be of some use to them.

When we know the particular user population very well, we may do even better, and be able to provide quite specific points of attachment for their culture and lifestyle, even to a limited extent for their individual comfort and support.

What has all this to do with meaning? And what about sensory richness or poverty? While we are at it, what about the psychologist's interest in stimulus simplicity and complexity? Do these concerns have any bearing on the subject? I believe so. Psychologists have been interested in the stimulus complexity versus simplicity paradigm for a long time. There is a long literature, nearly all of it in regard to controlled laboratory environments, and much of it using animals as subjects of experiment. As a result of their work, we know a few important basic things about behavior when confronted with stimuli of varying complexity.

The most important of these is that we choose complexity over simplicity from earliest infancy onward. We are a stimulus seeking species. Apparently, the more the better. But only up to a point; somewhere we begin to attend to these stimuli selectively, ignoring what is temporarily or permanently irrelevant and processing for use only that which is meaningful to us. At that point we have become able to make very rapid judgments. We filter out and focus upon the signal, and suppress the noise, allowing us to attend further to the signal. If the signal has strong learned associa-tion cues, we then attend further to the signal. The American tourist in Tokyo is oriented and reassured by his discovery of the Starbuck’s sign printed in English. All the other signs are ignored, the characters float, awash in his brain, unsorted, are soon down the short-term memory drain and are forgotten.

Let me propose a model to put these ideas into some order and relate them to one another: meaningful richness is complexity with which we have previous associations or experience. The key that opens up the issues of stimulus simplicity vs. complexity together with environmental richness vs. poverty is that for an environmental stimulus to be worth perceiving and remembering (or storing), and reacting to, it must bear some meaningful relationship to some aspect of our previous experience that match, in and of itself, is the stuff of meaning. Richness is not automatically the same thing as complexity because it may contain what we categorize as noise that we do not recognize or care about.

But, note that also: meaningful richness may be embedded within SIMPLICITY with which we have experience. Complexity and simplicity are not polar opposites when applied to issues of meaning in real world non-laboratory situations. The simple interior of a summer-rental cottage makes it’s behavior settings accessible to anyone. An early Quaker meeting house is relatively simple yet it’s simplicity was rich in meaning to Quakers (and because of culturally specific learning, it can never be quite as rich for the rest of us non-Quakers). To extrapolate a bit, we can also postulate that both MEANINGFUL RICHNESS and MEANINGFUL SIMPLICITY in the environment tend to support healthful experience and activity, and both may be emotionally complex and therefore meaningful.

As caregivers evaluating environments, we should be aware that the old mental hospitals, some nursing homes, penitentiaries, and some public schools are the only settings in the society that have ever been allowed to degrade to the point of true sensory impoverishment. It is paradoxical and tragic that the inmates of these kinds of institutions critically depend upon sensory adequacy. These kinds of institutional settings have an unenviable record of being stimulus poor, and barren of meaning. That particular combination is insidiously dangerous. As the ministers and overseers, the societal stewards of these environments, we must be especially watchful that the environments we manage do not backslide into empty reaches of polished VAT floor space lined with chairs at the walls, and filled with nothing to do. Such institutions require skilled frequent unscheduled public oversight and evaluation.

Environments can be maintained at high levels of meaningful richness only when the occupants are involved in their daily re-creation and maintenance. When the users are active protagonists of their own daily lives they will take over and invest their environments with meaning. Settings in which deprive people of choices on the other hand will eventually devolve to a totalitarian mode, stripped of meaning and attachments. Humanness is denied to their users when choice and setting deprivation rule.

Patienthood, characteristically and traditionally, has removed both the opportunity and the initiative for this kind of user-engagement from the hospitalized (or for the imprisoned). Their environments have never been allowed to develop the cultivated richness, the critical mass of objects and the appropriate behavioral options, that contribute to self-supporting, self-perpetuating environmental meaningfulness. Mental hospitals, nursing homes, schools for the developmentally disabled, and prisons are the only environments in the U.S. culture (as far as we know) that are routinely in danger of being so mismanaged that they can drive people terribly crazy. It is tragic that these populations, so vulnerable to begin with, are made even more helpless and miserable without the compassionate attention of the rest of society.

How can one guide health care administrators and care-givers, or their architects, and lead them through the process of evaluating whether a particular environment, or the design for an environment, might be sufficiently meaningful to its occupants? It requires at least one strong-willed person. I will use a mental health treatment environment in the example to follow, but the questions and information may be just as easily directed toward evaluating any other environment.

If we are ever to make use of insights and theory of this sort, it will be necessary to move from the abstract to the most concrete of environments—architecture on the ground. It will be necessary for the reader to evaluate an existing institutional environment with which he or she has some experience. If that is not possible, try to analyze the design for a new facility for which drawings are available. Failing these options with actual buildings or plans, try at least to remember the details of a particular environment.

Evaluating meaningfulness

Evaluating whether a particular environment is barren or sufficiently and appropriately enriched is easy—just lock yourself up! Find or imagine a nearly empty room, like a solitary confinement, or minimalist penitentiary cell and spend a day living in or imagining yourself confined to the space for six months. Remember that there are about one hundred and eighty real days in six months, so this is hardly as difficult as the real thing. What would you do with your time?

Make a list of the possible activities using the typical inmate or patient's daily schedule. Imagine pacing from corner to corner, or place to place as the bears and patients do. If your imagination isn't up to the job, and a real or a similar environment is available, sign yourself in and live as a resident on the ward for a week with no cell-phone. If neither of these courses of action are open to you (and I hope it is not for lack of courage, for you have to be able to take what you dish out, or if you can not ‘take it’, probably you aught to change the dish you have been preparing), make up a simple list of questions that you can ask (other) patients (within a day or two you will feel like a patient yourself). For instance: What can we do when we have free time? Where can we go? Do we go alone or with a group? How long does the activity last? How long do you usually stay? Are there other times during the week that you go there? How often does this happen? Are there other places, and other activities that you enjoy? What would you like to be able to do in addition or instead? If you were at home what would you be doing at that time of day? Ask also questions leading to very private and personal, even secretive space and privacy needs. Ask when they expect to be released.

It is not always necessary to become engaged in formal research protocol when doing evaluation. Often there is no budget for this work. We're dealing with rather subjective kinds of evidence anyway, and even anecdotal evaluation notes, if written actively and in a timely way when on site, will probably reveal that the patients strongly, and in concert, feel that the environ-ment is or is not satisfactory. If your exploratory questions do not reveal this kind of bias, and you are reasonably convinced that they ought to because of the "obvious" character of the place, then perhaps it may take more time to gain the trust of the patients you are interviewing. Or, consider making contact with someone who can help you construct a more rigorous research or evaluation procedure to pry out the data. This process works better if an enthusiastic group can do this work in parallel. If residents insist that the environment is great, OK, and just fine, then perhaps you have stumbled into the exception we all need to read about. Find out how and why it works and please publish a report for the rest of us.

There are other ways to find out if a setting is barren. Make an inventory of all the pieces of furniture and all the smaller objects such as magazines, ash trays, TV sets, tools, and so on, that are available to anyone in the setting on a daily basis without asking for special permission. Make a similar list, room by room, for one or two staff homes (or any other person’s home). Compare the lists for length and variety. What kinds of objects are missing in the institutional setting that could conceivably be included? Remember that if the institutional inventory is much shorter and less elaborate than the private home, the deprivations will be greater absolutely, and also relatively, because many more people use and share the institutional setting than the home so any object or setting in an institution is in far greater demand.

Where there are very few distractions or entertainments they may conflict or interfere with one another (TV versus piano) and their use must be controlled and alternated. Often such inventories reveal that there are almost no personal possessions of any more than utilitarian importance (toothbrush). Look at the dates on the magazines. If the task itself is depressing and you can't finish it, you will have discovered that the place has some kind of problem but failed to describe it.

The environmental problems you may develop personal reactions to may be the problem you are investigating. This work can be seriously depressing and sad. This is dangerous research. It is discouraging and disillusioning. Hospitals and hospital staff don’t need illusions anyway, so if you encounter these problems write about and discuss them. Don't let the intention get away from you or become so discouraged that you drop the project. You will have been standing in the shoes of every patient or inmate and are for a while, their advocate, perhaps their only advocate. Saturate yourself in the ambience until you can put it into words or you have yourself become a patient, and then put that into words. You must be tough-minded. Most people cannot keep focus or even keep awake in these kinds of environments for many hours at a stretch. Do you dare to close your eyes and sleep? The work will be more successful, and you will feel better, if you plan to break up the research with personal time, reading, etc.. But be forewarned that what may start out as revolutionary zeal might congeal into boredom within a day, so powerful is influence of being confined within a depriving environment. Expect that at the end of your workday you will be exhausted, and that even your own personal time and reading material may seem dull and meaningless in that environment.

I have never seen any institutional environment that was not seriously lacking in supports for its inhabitants. If you have to do rigorous funded research, first be certain that the people and agencies that trade dollars for statistical reassurances will follow through and correct any deficiencies that are identified. In this matter it is nearly guaranteed that the environment of every mental hospital and mental health center in the country is at fault. It is only a question of how, and how much.

When a place is sterile of sensory stimulation, empty, and meaningless, schizophrenics (who make up a majority of all mental hospital diagnoses) may be all the more likely to drift off into private worlds. Enriching the sensory environment may not have a noticeable effect on their illness, but it will make them appear less bizarre to each other, to their visitors, and to themselves. At least, an enriched setting might create an expectation of possible future health. Perhaps a good environment is one, in this case, which attempts to do no one any harm and can maintain the expectation of eventual recovery.

The object of your personal participant-observer journey within the institution may have an immediate benefit to the users— using the information you gather you may be able to re-arrange the furniture to correct its behavioral barrenness at no cost to the institution. Your attention to the people and the environment will also be welcomed All the small objects and furniture in the world will not add up to a sen-sible and useful setting if they are not selected and organized in a way that reflects the day-to-day life needs of the users. For example—a large department store usually contains all the essentials and most of the amenities for daily life of an enormous number of people. However no one can actually live in such a place because it is organized all wrong. There is order, but the wrong order. Beds are with beds, chairs with chairs, etc.. The environments of total institutions are usually almost in the same condition. The only order that can be discerned is the one that is laid out by the maintenance staff and the ward personnel—an order designed around janitorial routines and patient management. The chairs side by side along the walls, the card tables in irrelevant places make room for the floor polisher and mops, and the large lounge chairs may be in anti-social (socio-fugal) rows like theater seats before the TV screen. No one lives like that at home, not the janitors, the nurses, or the patients. If they did, they would soon go nuts with boredom. That is exactly what happens in the hospital.

Have you heard, as I have, the refrain arising from a wander-ing, pacing patient (and patient he must be to wait out his dull stay) "there is nothing to do in this place?" If the environment reflects that serious lack of an active and creative therapeutic program, then changes to the space will not accomplish anything. The whole treatment program and health care system and the unit treatment plans are probably in serious trouble, and should be examined by an outside group.

In such situations, look for causes further back at the level of therapeutic program goals, and how they are being carried out in practice. If there is no agreement about defined goals, or if they are not operational, work on that first. Translate those goals, once you have them, into specifications for an ideal setting, an environment that anyone, not only yourself, would be sure of understanding and not be uncomfortable living in. Then try to build that understanding into new furnishings and space planning for the unit.

Every single piece of furniture and every grouping of furniture, carries a message—"sit here and escape from social contact" or "lie down on me and hide in this out-of-the-way corner." Attempt to replace messages of retreat and defeat with messages more like' 'please join this group of reasonable, friendly, non-threatening people," or "come in and learn a new skill."

Every room should have some identifiable use, some organizing principle around which people can structure their behavior. In ordi-nary life and ordinary houses we have dining rooms, bedrooms, kitchens, work spaces of various kinds, studies, and so on. Match that with the common names of spaces in the hospital. What does one do in the day room? Day? In many hospitals, patients are not allowed in their bedrooms in the daytime. This leaves only corridors, bathrooms, stairways, and dayroom lounge spaces open to those who cannot leave the building. What desirable or therapeutic behavior can be associated with these spaces? How can anyone get better in such a mind-numbing collection of no-places? The answer is usually no-how. How can the staff of such hospitals expect to build faith and credibility with the patients perched on the edge of a cold plastic and aluminum chair? Why in the world should patients believe that their recovery is of any concern to the wardens of such gross, cheap, empti-ness?

There is literally no sign of concern or caring in such environments. In a television performance of a Bergman screenplay, The Ritual (1969), one of the characters, living in a mental hospital, receives a visit from his sister. In his bare room they sit facing each other, awkwardly, in the center of the space. Their hands are in their laps. She smiles nervously to reassure him. Several aborted attempts at conversation give way to:

He: “Would you like anything? (…pause). (apologetically…) I have nothing to offer you here (…pause). A banana? (…long embarrassed pause).”

That moment was one of the most accurately observed and most minutely painful of any I have seen in drama. He, the patient, was utterly without support from his environment. His environment had collapsed and evaporated, and with it collapsed the foundations of all his hospitable behavior and self-confidence, leaving him only with “hospital behavior” and helplessness. That, and his illness caused the disconnection with his sister.

The longer a person is confined in environments that restrict opportunity and activity, the more serious and disturbing will be their effects upon him. “Normal” people fare no better when their environmental props and settings are removed, but few have the courage to test their endurance in these settings. Actors must have heroic confidence, and work much harder, in order to perform on a bare stage with no stage settings.

If you don’t believe the degree to which I attribute dependence upon the small behavior props in your own world, try an experiment: the next time you invite friends to your house, first prepare your house: entertain them in a room from which you have removed everything but one or two hard chairs. No rugs on the floor, no food, or drinks—empty, like the Bergman movie-setting.

Not only are you and your friends likely to have a miserable and probably quite short evening (it would be worse in the daytime, because you would all have the sense that while you suffered, the world moved along outside the window, and you would not be a part of it). Your friends will probably ever afterwards perceive you through the memory of that weird experience—their opinions and expectations for you having been permanently tinted by that unexpected episode—would you risk this personal stigma?

Mental hospitals and similar institutions are so far from the beaten path trod by the ordinary person that they have evolved without the continuous supervision and modification and refurbishing that occurs in other kinds of work places and healing places. Consequently, there is little or no pressure on these building types to continuously evolve into a developing building genotype. Few outsiders visit, and when they do, they are often unskilled observers, under stress, and without the power to influence the organization. They are often frightened, or at least apprehensive, involved with their friends’ illness, and they depart unable to sort out or understand the many unusual sights, sounds, smells, and other impressions they have received. They need to forget or ‘get over’ the nasty experience and get back to ‘normal life’ as quickly as possible. The powerful stigma of hospitalization, in the past, has prevented open public discussion of hospital conditions. Patient advocacy groups and patient groups themselves were slow to rise and are fragile. Without continuous formal public review, these environments go to hell.

Approaching an optimal institutional environment

An optimum hospital environment is one formed as closely upon models of ordinary, everyday environments as might be experienced by a typical member inmate population to be served. In addition, the environments of the larger institutions, and any total institutions which house patients for continuous twenty-four-hour cycles, should be capable of supporting a very wide range of ordinary human behavior. This range of behavior should probably include behaviors that are not usually thought to be part of institutional routine. Readers interested in pursuing the issue of wholeness in more detail are referred to the Theory of Archetypal Place and its inventory of behavior-place types. Hospitals designed to rule out behaviors which are not usually included in hospital routine are likely to impair the functioning of their clients both during and after the hospital stay.

Four first-order responsibilities should be reflected in the design of Institutional environments:

1. Provide enriched settings that will aid in the recovery and rehabilitation of each patient.
2. Provide settings that will allow the patient to maintain as complete a behavioral repertoire as was within his or her capacity prior to Institutionalization.
3. The Institution must not diminish the scope and completeness of the patient's behavioral repertoires.
4. Institutional environments designed with meaning in mind must offer the fullest possible support to the hospitalized patient's strengths throughout the hospital experience, from the first day of admission onward.

At the least, an intentionally planned, meaningfully designed and critically evaluated Institutional environment will do less harm than the monstrous old hospital up on the hill.