A Q&A with Dr. Naomi Sachs, assistant professor in the department of plant science and landscape architecture at the University of Maryland. Sachs has a Ph.D. in architecture from Texas A&M and a master's in landscape architecture from UC Berkeley. She is Founding Director of the Therapeutic Landscapes Network and Co-Editor of the Health Environments Research & Design (HERD) Journal.
Jack Reed, architectural designer at EYP Denver, a former Tradewell Fellow who has conducted research on the therapeutic influence of biophilia, talked with Sachs about the importance of bringing natural elements, views, and access into behavioral health spaces. “A lot of the benefits of biophilia are psychological,” says Jack, “so behavioral health seemed like one of the areas with the greatest potential for impact.”
EYP has worked on the design of several spaces at the University of Maryland, including the A. James Clark School of Engineering, College Park, as well as numerous behavioral health spaces nationwide.
What attributes of nature exposure are most beneficial to mental/behavioral health?
Sachs: It depends on the patient and their condition. If it’s mental health and someone is struggling with burnout, anxiety, depression, there’s a much higher potential for a nature connection to be beneficial, even passively. But that should include more than just seeing pictures of nature or viewing it from a window.
Nature can help with anxiety, serving as a positive distraction and engagement, as mentioned in Ulrich’s theory of supportive design. Green plants and natural light are much better for one’s mental health than, say, sitting in a windowless room under fluorescent lights watching television.
More active interactions, such as those available in outdoor gardens, encourage social interaction and physical movement and exercise, not to mention providing a dose of vitamin D, which affects bone strength (among other benefits). Activities like gardening, jogging, walking outside, even sitting in the shade, are ways of forming a deeper, more holistic connection with the earth.
Can you talk about the relative benefits of views to nature, physical access to nature, daylight, and natural ventilation?
Sachs: We know that natural daylight exposure supports our circadian rhythms. For people dealing with issues of psychosis, depression, or anxiety, it’s important for them to have this sense of time and circadian balance. Views to nature are inherently tied to daylight exposure, but physical access to nature and direct sunlight is very important as well.
Natural ventilation, like opening a window, is also beneficial. Dr. Mardelle Shepley, of Cornell, found that opening windows was highly desirable, even just a crack. To individuals, that symbolic “breath of fresh air” was important – a pressure release. Being able to open windows feels like freedom even if the air quality outside is not any better. With COVID-19, we have learned just how critical fresh air can be.
With nature, it’s often the variability that gives us that positive response. For instance, airflow from a ceiling fan is consistent and feels mechanical, but an outdoor breeze varies in speed and temperature and feels more natural. How can we bring those non-rhythmic sensory stimuli, which evoke a biophilic response, into our designs?
Sachs: Well, choice and control can be some of the most important factors, especially in behavioral health facilities where you have so little of either. The ability to dim lights, open and close blinds, select the temperature in your room, look outside…those small choices are powerful.
And letting people go out into a garden – even if they must be accompanied – is another way to allow people to experience air and temperature changes, shade and sun. However, if there is a garden right there outside my floor that I can see, but no one is letting me go outside and the door is always locked, that could be really frustrating.
With behavioral health, individuals are usually physically able to go outside (unlike, for example, in a cancer care facility with severely immunocompromised patients) and it would really benefit them. Nature does a better job of multi-sensory engagement than interior elements.
What attributes of nature would you consider essential? Could restricting someone’s physical access to nature do more harm than good?
Sachs: In a behavioral health setting, I think greenery is essential. If we take a more philosophical approach, nature is everything, and we are part of nature. So there is a pragmatic, evolutionary point of view to support biophilia: we all need air, water, daylight, plants, etc. to survive.
Plants have a softness, they help with the heat island effect. Trees or large shrubs help with shade and cleaning the air through photosynthesis and filtration. Plants and trees also attract animals, birds, butterflies, beneficial insects, and so on.
A variety of plants is important, not just a lawn. You should provide a range of sizes, scales, textures, colors, and seasonal interests. You don’t want the garden just to be there for the summer and then a bunch of dead twigs in the winter. Rather, you want to be able to see, for example, bright berries on a shrub and evergreens year-round.
You’ve previously mentioned the importance of shade in outdoor spaces; I couldn’t agree more. But how can we as designers counter challenges related to safety or cost? When shade structures and trees are the first to go, what evidence or research supports keeping them?
Sachs: By not providing shade in outdoor spaces, facilities are doing harm. It’s a well-researched fact that people on psychotropic medications (and so many patients and residents in MBH facilities are on at least one psychotropic medication) are more susceptible to UV rays and that people with sensory processing disorders are more susceptible to glare, which can be caused by too much sunlight or light surfaces (marble, unstained concrete, metal furniture, etc.) Aging patients also may suffer eye strain and are more susceptible to UV and glare.
There are safe ways to provide shade where ligature is not a risk. Or perhaps the issue is solved programmatically, where a patient/resident is always accompanied by at least one staff member outside or is visible from indoors. Suicides rarely happen outside; most suicide attempts occur in bathrooms or indoor private spaces, not outside.
How can architects successfully advocate for the design of biophilic spaces? How can we best make a convincing case to owners, designers, developers, etc.?
Sachs: I think by demanding these biophilic spaces. Providing access to nature and natural elements should not be optional, just like providing a bathroom is not optional.
In addition to clients, behavioral health staff members are also a major consideration; they are there for long shifts under incredible stress. They also need spaces for respite and stress relief, which will result in better care. Architects can promote resilience by enabling a nature connection.
Is it fair to say that biophilia should become part of our basis for design?
Sachs: It could be, yes. My problem with biophilia is that sometimes it can get so distilled: “We’re putting in wood and that’s a natural material, so we’ve ticked the biophilia box,” or it’s just walls with leaf patterns on them. If biophilic design becomes too abstract, no one is going to relate to it as nature. It becomes a checklist.
“One of the most fundamental effects of nature exposure is that it reduces stress. Stress is itself harmful, but it also exacerbates just about any other mental/physical condition. Nature helps with depression, anxiety, aggression.”
What needs to happen for the industry to adopt biophilic design? For example, addressing gaps in research, more advocacy, code requirements, more conclusive evidence?
Sachs: All of the above! What we don’t need is more general research saying nature is beneficial; we know that. What we need is specific research. What spaces do specific patient groups need? For example, in most gardens, scented plants would be beneficial -- but not for everyone, e.g., cancer patients who are sensitive to certain smells.
Research has to come first, addressing gaps and providing conclusive evidence simultaneously. Then, code can be based on this information. I do think codes are important. If something is required or mandated, that really helps.
Advocacy should include providing the business case as well as evidence for patient outcomes, the health case. Ulrich’s 1984 ‘View Through a Window' study found three important aspects that all impact a healthcare facility’s bottom line (recover faster, need less pain meds, complain less to nurses). Doing the right thing provides better outcomes for patients and staff and saves money. A win-win-win.
What is the best way to communicate findings, evidence, and past examples?
Sachs: A systematic literature review, or scoping review, which analyzes hundreds or thousands of studies and synthesizes and summarizes them. Trusted organizations like Terrapin Bright Green, Biophilic Cities Network, and the Center for Health Design are great resources that pull and compile the most salient and convincing evidence.
Case studies are important as well. They provide examples of when something has gone well. “Look, these folks have an indoor garden and an outdoor garden where people are allowed, these are the physical designs they’ve used and the programmatic policies they have, and this is how it’s working.” That makes it a lot easier to argue for than just saying, “Well, theoretically, when people have access to nature they are (for example) less aggressive.”
Pre- and post-occupancy evaluations can be highly effective. These are a lot harder to do in behavioral health facilities because it’s harder to get in and to get IRB approval. But I think we can learn a lot if we are able to get over that hurdle.
Three Keys to Biophilic Design for Behavioral Health
In summary, Jack highlights three considerations for the design of therapeutic spaces that leverage nature’s healing potential:
- Create multisensory spatial experiences: As important as it is to provide views to nature, it’s equally vital to account for the other senses in an engaging and holistic way. Natural conditions are dynamic and ever-changing, so a simple breeze can provide thermal, auditory, and olfactory stimulation in addition to visual patterns of light and motion as it interacts with water or foliage. Physical access to nature also fosters a mental and physiological connection between a person and their environment.
- Provide choice and control: Behavioral health patients are known to benefit from having a sense of agency and individual choice, and these principles include not just the built environment, but natural elements as well. Effective designs should incorporate a range of environmental conditions: both sun and shade, sound and silence, openness and privacy. Offering a variety of physical settings will increase a person’s comfort range and allow them to engage with the environment as they please.
- Design for staff as well as patients: Even the most patient-centered design can only succeed if it also accommodates staff members and promotes a positive relationship with patients. Designers should provide dedicated break rooms and outdoor spaces for staff that take advantage of nature to allow for respite and relaxation. These areas can be more flexible without the same security concerns of elopement or ligature risk, and reducing stress on clinicians will ultimately translate into better patient care.