Healing Environment in Psychiatric Hospital
Design
Raz Gross, M.D., Yehuda Sasson, M.D., Moshe Zarhy, Architect,
and Joseph Zohar, M.D.
Abstract: Mental health professionals have long speculated
that the physical environment in which treatment occurs has
an impact on both the treatment process and its outcome. The
few empirical studies that evaluated the effects of psychoenvi-
ronmental design have shown encouraging results and demon-
strated clinically desirable behavioral changes and even reduced
psychopathology. In view of the concept that architecture is a
tool in the therapeutic process, the design and execution of the
psychiatric hospital in the Chaim Sheba Medical Center at
Tel-Hashomer, Israel, were conducted by a multidisciplinary
team of architects, mental health professionals, and adminis-
trators. The hospital contains three acute inpatient wards and
a day care and large outpatient clinic. Its operation began in
1991. This paper deals with the merging of “user-friendly”
architectural and environmental design components that create
an integral healing environment. The paper discusses the pos-
itive effects of specific components on patients and staff, and
suggests that our model of psychoenvironmental approach to
psychiatric hospital design can provide an important and ef-
fective tool in the pursuit of a humane, efficient containment
and reduction of severe psychopathology. © 1998 Elsevier
Science Inc.
Introduction
We shape our buildings, thereafter they shape us.
(Sir Winston Churchill. TIME, Sept 12, 1960)
Mental health professionals have long speculated
that the physical environment in which treatment
occurs has an impact on both the treatment process
and its outcome [1–3], and they have paid increas-
ing attention to the interrelationship between this
Division of Psychiatry, The Chaim Sheba Medical Center,
Tel-Hashomer, and Sackler School of Medicine, Ramat-Aviv,
(R.G., Y.S., J.Z.) and Zarhy Architects LTD, Tel Aviv, (M.Z.).
Address reprint requests to: Raz Gross, M.D., Division of
Psychiatry The Chaim Sheba Medical Center, Tel-Hashomer
52621, Israel.
108
ISSN 0163-8343/98/$19.00
PII S0163-8343(98)00007-3
physical environment and behavior [4,5]. However,
relatively little interest has been shown in the ther-
apeutic potential of psychiatric architecture [6].
The few empirical studies that evaluated the ef-
fects of psychoenvironmental design have shown
encouraging results. Higgs [4], for example, found a
decrease in pathological behavior following a move
of schizophrenic patients to a modernized unit.
Gabb et al. [7] demonstrated the positive influence
of the interior design of a public psychiatric facility
on the creation of a supportive, stabilized environ-
ment for schizophrenic patients. Christenfeld et al.
[8] showed selective behavior and attitude changes
among both staff and patients after transition to a
remodeled ward, as compared with matched con-
trol wards. Notably, one of the changes was a sig-
nificant decrease in the rate of patient violence.
Stahler et al. [9] found an increase in patient-staff
interaction and a decrease in pathological behavior,
together with improved morale among both pa-
tients and staff, after a remodeling of a psychiatric
geriatric ward. Whitehead et al. [6] measured be-
havioral changes in a clinically desirable atmo-
sphere subsequent to the redesigning of a psychi-
atric unit. These changes also correlated with
reduced psychopathology, probably secondary to
the betterment of staff-patient contact.
Some authors [10] suggested that even minor
architectural changes can lead to significant im-
provement in how the setting functions, with pos-
itive effects for patients, staff, and families. Sommer
and Ross [11] reported, in one of the earliest works
on this issue, a doubling of the rate of social inter-
actions among geriatric patients following the rear-
rangement of furniture in a day room. Minde et al.
[12] showed similar effects of restructuring a day
room on psychosocial functioning, as well as on the
General Hospital Psychiatry 20, 108 –114, 1998
© 1998 Elsevier Science Inc. All rights reserved.
655 Avenue of the Americas, New York, NY 10010
 Figure 1. The Sheba Medical Center Psychiatric Hospital.
109
R. Gross et al.
quality of life, also in psychogeriatric patients. Co-
rey et al. [1] proved that even simple redecoration
of the psychiatric ward, such as changes in furni-
ture style, floor covering, and color scheme, could
have a favorable impact on staff members’ and
patients’ perception of the psychosocial milieu.
Another architectural change that reportedly
might bring clinical benefits is structural division of
the ward into smaller units. Wilson et al. [13]
showed that structural division provided contain-
ment of incidents and reduction of vandalism,
110
Figure 2. Open porch of one of the
wards. Note how the porch is con-
tinous with the lawn.
stealing, and acting out in a psychiatric hospital for
adolescents.
Findings from the above-mentioned studies, as
well as other publications, support the speculation
that altered physical design variables, consistent
with treatment philosophy, would be associated
with favorable changes in staff and patient percep-
tion of ward atmosphere [1], and would have a
therapeutic value [6]. Indeed, congruence between
patient and staff perceptions of psychiatric wards
has long been considered a necessary factor for
Figure 3. Main entrance of the Psychi-
atric Hospital.

effective system functioning, although at least one
study showed that those perceptions were higher
for staff than for patients, and challenged the belief
that such congruence is an indicator of program
quality. In fact, the authors [14] believed that to
expect congruence of perceptions may be unrealis-
tic.
To measure the psychosocial atmosphere of treat-
ment environments, investigators often use the
Ward Atmosphere Scale (WAS), which was devel-
oped by Moos and Houts [15] in 1968. This is a
Healing Environment in Psychiatric Hospital
Figure 4. The main hallway. Note the
natural daylight coming from the ceil-
ing.
100-item true/false questionnaire that is easily ad-
ministered to patients and staff, and specifically
assesses their perception of psychiatric inpatient
treatment environment along three dimensions: re-
lationship variables, treatment variables, and sys-
tem maintenance variables [1].
Another measurement instrument is the Behav-
ioral Environment Assessment Technique, which is
derived from ethological studies and measures
ward behavior. The procedure has proven effective
in several studies of psychiatric patients [5,16] and
Figure 5. Another view of the main
hallway. Note the patio on the left
hand side.
111
R. Gross et al.
in assessing change among them [17]. Thus, the
positive effect of the so-called healing environment
on psychiatric patients can be measured by valid
tools and not recognized merely by global impres-
sion.
An important finding in the study by Whitehead
et al. [6] was that length of patient stay was not
substantially affected by the ward redesign. This
observation is meaningful because it is sometimes
argued that providing a humane clinical setting
will hamper staff efforts to discharge patients be-
cause of resistance to leaving the ward. Indeed, we
may assume that in a healing environment the pa-
tients are more likely to improve clinically faster,
and get discharged sooner.
It is clear from this review that attention to the
design of the physical environment of a psychiatric
hospital can provide major support for patients and
their treatment programs [18], as well as for the
staff and families. Cooperation between architec-
ture and psychiatry is therefore essential [10], and
should be maintained during each phase of a
project [19]. French psychiatrists Sivadon [20] and
Amiel [21] simultaneously assumed the responsi-
bility of relating to, and actively participating in,
the design process of the healing environment. The
results of their pioneering experiments, and their
implementation, can be seen at La Verriere Hospital
near Paris [22].
In view of the conception that architecture is a
tool in the therapeutic process, the design and ex-
ecution of the psychiatric hospital in The Chaim
Sheba Medical Center in Tel-Hashomer, Israel,
were conducted by a multidisciplinary team of ar-
chitects, psychiatrists, and other mental health pro-
fessionals and administrators, thus including the
consumer as an active element in designing the
facility [22].
The hospital contains three acute inpatient open
wards, a day care clinic, and a big outpatient clinic.
Its operation started in 1991. This has provided
enough time to evaluate the influence of the design
features on the patients’ well being and the recov-
ery process.
The Psychiatric Hospital is an integral part of the
biggest medical center in Israel. Its location within
the premises of a medical center allows ongoing
interrelation and dialogue between the medical
staff of the Division of Psychiatry and that of the
other wards. The psychiatrists provide regular
consultation-liaison services to the latter, and con-
sult with physicians from other wards on nonpsy-
chiatric medical issues. Patients suffering from both
112
mental and physical disorders, which are often in-
teracting and share reciprocal clinical impact, are
benefiting daily from this arrangement. The loca-
tion within a general medical center also facilitates
the routine use of laboratory and brain imaging
services, thus enhancing the level of medical care.
In addition, it symbolizes the medicalization of psy-
chiatry and alleviates the obvious apprehension of
patients and their families regarding admission to a
psychiatric institute.
The daily clinical observation by the staff leaves
no doubt that the patients enjoy their physical en-
vironment as it offers them a safe, comfortable,
nonthreatening, and readily comprehensible set of
surroundings. The messages sent by the physical
environment convey sincere respect for the patient
and sensitive concern for his or her physiological
and psychological well-being, which are important
contributors to the therapeutic process [23].
The design of the inpatient wards adheres to the
basic set of guidelines for ward design: patients are
not overcrowded or overconcentrated, so they are
not forced to interact with too many people. They
are given the opportunity to retreat physically
when they feel threatened, and to form beneficial
relationships [24]. The latter is achieved mainly by
providing a variety of spaces that support social
interaction [18], such as a big day room, a dining
room that is well lit and ventilated [19], and spa-
cious lobby and corridors, whose design resembles
that of a living room with residential furniture
rather than commonly used institutional pieces.
The open porches of this one-story building are
almost continuous with the lawn that surrounds
them, thus providing further spaces for social inter-
action, and creating a free and unthreatening atmo-
sphere while at the same time helping to define
space. Generally, it seems that patients and staff
react positively to the classical daylight and fresh
air.
The nurses’ stations are located in front of the
day rooms, separated by big windows that are usu-
ally open. It is noteworthy to mention that an im-
portant negative finding in the study performed by
Whitehead et al. was the small number of patients
who spent their time near the open nurses’ station
[6]. Nurses often fear that patients will abuse their
easier access if the nurses’ station is open. The data
in this study prove this fear to be unrealistic. More-
over, it appears that the openness of design may
encourage staff to leave the station and spend more
time in the day room [6].
The building is well kept, with meticulous daily

maintenance, and repairs are carried out promptly.
This is essential, especially when vandalism or ac-
cidental damage occurs; constant maintenance dis-
courages more destruction [19].
Safety in the psychiatric setting involves many
aspects of facility design [25]. To mention a few,
most of the patient living area can be easily ob-
served by staff, lighting in the patients’ rooms is
sufficient for adequate staff observation during
evening and night hours, there are many exits
which could be used in case of an emergency, and
the building is equipped with smoke detectors and
fire extinguishing equipment.
As already mentioned, environmental conditions
are important to the efficiency of the staff operation
[22]. The staff’s working and resting areas are seg-
regated and are provided with separate entrances,
yet are easily accessible to patients and their rela-
tives. Thus, boundaries are defined without sug-
gesting alienation. It is unanimously agreed by all
staff members that the physical environment in the
psychiatric hospital contributes also to the quality
of life and sense of professional dignity of the work-
ers.
The humane, efficient containment and reduction
of severe psychopathology is a major goal shared
by hospital designers, clinicians, and administra-
tors [6]. Our model suggests that a psychoenviron-
mental approach to psychiatric hospital design can
provide an important and effective tool in that pur-
suit, and supports the prediction that a planned
environment may favorably impact both patient
and staff.
The concept that “medical care cannot be sepa-
rated from the buildings in which it is delivered,”
and that “[T]he quality of space in such buildings
affects the outcome of medical care” [26], is gaining
increasing attention. This concept holds true espe-
cially in the case of psychiatric wards. Once in the
domains of a general hospital, the psychiatric ward
might suffer from the tendency of hospital archi-
tects and designers to focus on providing adequate
space for new technology, and on maximizing func-
tional efficiency [26]. It is the role of psychiatrists
and other mental health workers to redirect the
focus of ward design to the patients and their fam-
ilies, the consumers of hospital services. The psy-
chiatric unit of the general hospital offers unique
opportunities for the psychiatrist, nurse, adminis-
trator, architect, and designer to pool their talents
for the benefit of patients with mental disorders
[27].
Healing Environment in Psychiatric Hospital
As Sir Winston Churchill’s [28] aphorism implies,
buildings are shaped by people for people. When
well shaped, they can help ailing people get into
better shape.
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