Written by: Vedika Kabra, Moitrayee Das
A Pennsylvanian state psychiatric facility undertook the responsibility of redesigning its physical environment in 2011, with the intent of reducing restraint and seclusion rates. The results were astounding, with the initiative showing an 82.3% reduction in both. The researchers then conducted a follow-up study to assess the longitudinal effectiveness of the initiative, and the results supported the conclusion that environmental changes in facilities can make these reduced rates sustainable (Borckardt et al., 2011; Madan et al., 2014).
Still, in most psychiatric facilities you walk into, you will encounter harsh fluorescent lights, gray walls, layouts designed to facilitate surveillance, and windowless rooms—making their design convenient for imposing restrictions and seclusion on patients. This lack of consideration in institutional design is not due to a lack of research but rather a failure to prioritize architectural and interior design as legitimate supportive clinical interventions with measurable outcomes.
Empirical Evidence on Therapeutic Design
Beginning with Roger Ulrich’s 1984 study, which put architectural design as a healing intervention on the map, and extending to a 2024 systematic review analyzing 44 peer-reviewed studies, research on the impact of the built environment on mental health outcomes has spanned decades. Ulrich’s foundational study found that surgical patients with views of nature from their windows experienced faster recovery and required 30% less pain medication than those whose windows faced a brick wall (Ulrich, 1984).
Similarly, the 2024 systematic review included studies from nine countries and confirmed that multiple design factors—such as number of beds, lockable doors, nursing station design, acoustic environment, artificial and natural daylight—play a vital role in recovery in mental health facilities (Rodríguez-Labajos et al., 2024). The strongest evidence relates to reductions in seclusion and restraint.
In their 2021 systematic review, Oostermeijer and colleagues found that beneficial physical environments—including the introduction of warm colors, carpets, plants, natural light, low-stimulation spaces, gardens, and quiet areas—resulted in a significant reduction in restraint. The studied elements were similar to those in Ulrich’s 2018 study, where evidence-based design elements—single bedrooms, nature views, daylight exposure, garden accessibility, and noise reduction, among others—were implemented and led to a 50% decrease in physical restraints (Ulrich et al., 2018).
The effects of architectural and interior design extend across multiple domains of the built environment, and several studies have examined specific aspects. Nanda et al. (2010) studied art and anxiety and found that visual art depicting natural landscapes reduced anxiety and agitation in patients compared to other types of artwork. Benedetti et al. (2001) replaced bright artificial light with sunlight and observed a mean reduction of 3.67 days in hospital stays among patients with bipolar and unipolar disorders when exposed to direct morning sunlight.
These elements must not be seen merely as aesthetic preferences but as active, complementary therapeutic interventions with measurable clinical outcomes that can alter a psychiatric patient’s recovery trajectory.
The Science Behind Therapeutic Design
Multiple theories explain how the built environment facilitates psychological and physiological recovery. Stress Reduction Theory posits that beneficial built environments can reduce blood pressure, heart rate, and cortisol levels (Ulrich et al., 1991). Biophilic theory suggests that humans are naturally inclined to affiliate with natural systems and processes (Heerwagen et al., 2013).
Patients’ stress levels are often elevated due to harsh lighting, continuous noise, and lack of privacy. In contrast, safe and therapeutic surroundings communicate that recovery is achievable. Patients may find it difficult to cooperate and progress when the environment itself feels uncomfortable or perpetuates pessimism.
Barriers to Implementation
Despite the abundance of empirical evidence, the architectural and interior design of many psychiatric facilities contradicts the principles of healing architecture. Most facilities prioritize surveillance over patient autonomy, and materials are often chosen for durability rather than therapeutic value.
However, the gap between research and implementation is not accidental. Cho (2023) found that while architects personally believe architecture is fundamentally therapeutic and should incorporate natural daylight, air quality, privacy, and rest areas, firms tend to prioritize exterior appearance, space layout, and orientation.
The persistent belief that therapeutic design compromises patient safety must be challenged. The claim that “having windows presents patients with opportunities to break them or become violent” is outdated. Recent studies show that quiet spaces, gardens, sunlight, and low-stimulation areas actually reduce safety risks (Oostermeijer et al., 2021). Shatter-resistant windows, screw-secured planters, and double-sided lock doors are readily available solutions—it is largely a matter of choice.
Even though knowledge exists, there is still no universally accepted definition of “healing architecture,” contributing to the implementation gap.
Addressing the Objections
Hospitals and psychiatric facilities often argue that mental health departments receive limited funding, forcing them to prioritize hiring skilled therapists over investing in infrastructure. This objection assumes that architectural design and staffing shortages are mutually exclusive problems requiring separate solutions. However, past data suggest otherwise.
Madan et al. (2014) found that physical environment changes reduce rates of seclusion and restraint, which in turn lowers staff resource consumption. Every prevented restraint or seclusion incident redirects staff time toward therapeutic interventions rather than crisis management. While design does not eliminate workforce shortages, reduced patient agitation and restraint incidents allow staff to invest more time and energy in therapy.
Several studies have also examined this issue from a financial perspective. Cost-benefit analyses have concluded that improvements in well-being and satisfaction outweigh the costs of such interventions. Measures such as improving lighting, rearranging furniture to create open layouts, introducing nature views, and adding landscape artwork are relatively low-cost yet have lasting impacts on patients.
Moreover, the 50% reduction in restraint documented by Ulrich et al. (2018) suggests significant financial savings. Shorter hospital stays would increase bed turnover and potentially enhance revenue. The question is not whether we can afford therapeutic design, but whether we can afford to continue overlooking it while patients spend weeks in environments that impede recovery and increase operating costs.
The Way Forward
It is essential to recognize and legitimize architectural and interior design as therapeutic interventions rather than mere aesthetics. Professionals must be trained to consider the therapeutic environment when creating treatment plans, and built-environment quality standards should be integrated into clinical guidelines.
A shift from reactive to proactive design is necessary. Evidence-based design must become standard practice in new facilities. Existing facilities should undergo audits, followed by structured development plans focusing on low-cost, high-impact design modifications.\
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Vedika Kabra is a student at FLAME University, Pune and Moitrayee Das is an assistant professor at FLAME University, Pune. She can be reached at: [email protected]