by Wayne Jonas
Ulrich launched a research field exploring the effect of space on healing outcomes. So far this growing field has shown that:
• Single-bed rooms in hospitals can reduce infections; reduce falls; improve patient sleep; improve patient, family, and staff communication; and improve satisfaction with care.
• Natural light can reduce medical errors and length of stay; improve sleep, depression, and pain; help premature babies gain weight faster; and improve patient and family satisfaction.
• Exposure to nature can reduce pain, the stress of hospitalization, and the length of the patient’s stay, and improve satisfaction.
Other space and environmental characteristics also impact health, including noise, ventilation, artwork, furniture arrangement, and the availability of family and private spaces. Recent research shows that the health care environment can save money, reduce employee turnover, and attract patients—all good for the bottom line. This research is now known as evidence-based design and optimal healing environments (OHE)—an area in which I have focused much of my own work (more on this shortly).
Most changes to create an OHE have been done in acute care. But when used for chronic illness, as done in many cultures over centuries, the impact of an OHE can bring about significant and sustained healing. Clara, a patient of a colleague of mine, used the external dimension to heal herself, when even the best of medicine could not.
CLARA
Clara had been a vibrant and loved teacher at a school for foster children in Baltimore. With three grown children of her own, and a supportive husband, she had retired from teaching to devote her time to community work in the city. All was going well in her life when she was struck by a mysterious illness. It started with fatigue and gradually progressed to muscle weakness and then muscle wasting. She lost an alarming amount of weight and became depressed. Her work in the community was important, but the disease progressed and forced her to give up the work and spend more and more time in bed. Even going to the kitchen to fix breakfast exhausted her. “What is happening to me?” she lamented.
With the help of her husband she began to look for a cure. She had access to and saw specialists throughout the country—at Johns Hopkins, Columbia, Harvard, Wisconsin, Stanford, and UCLA. Multiple hypotheses were entertained. She received multiple diagnoses and tried multiple treatments, some with reasonable evidence, some experimental. What was it? Chronic fatigue syndrome or myalgic encephalomyelitis? Autoimmune myositis? A prion disease? Multiple chemical sensitivity syndrome? Mitochondrial deficiency? Major depression? Psychosomatic disorder? Clara needed a name for her illness, but no one could give her one.
Her hair began to fall out. Soon she needed to hire someone to help her with basic activities of daily living—dressing, cleaning the house, and getting around. She then went to nutritional and alternative medicine doctors. They suggested other causes. Food allergy? Nutritional deficiency? Adrenal fatigue? Yeast overgrowth? Dysbiosis? Chi imbalance? Dosha imbalance? Soul loss? She got a lot of names—but no relief.
It was all the more puzzling because Clara seemed to already have all the elements of health and healing in her life—a supportive family and friends, a good diet, a nice home, and access to the best medical care, both conventional and complementary. Still, she could barely function. One day a friend was visiting and the conversation went from updates on events in the community to Clara’s future. Instead of considering what else she could do, her friend asked Clara if there was a place she loved the most and felt happy and well. Clara immediately knew. “Well, yes,” she said. “It is in the mountains. My husband and I have a small cabin up in New England. I love being there. It is deep in the woods on a small lake. The animals visit. The light and sounds change by the moment. The silence is wonderful. I can see the mountains from our back porch. The place restores my soul every time I go. But I have not been able to go for a long time because of my illness.” There was a pause in the conversation as her friend just waited for her to continue.
In that moment, Clara knew what she was going to do. She had to go to the mountains. It would be difficult, as she could barely take care of herself. But her caregiver would go with her, and between her caregiver, her family, and her friends, she just might be able to stay for a while.
“But what about your doctors and therapy visits?” her friend asked. “What will happen to you if you give those up?”
Clara thought a moment. “I don’t know.” She took a deep breath. “All the diagnoses and treatments I have done so far have not helped. I think I need to take things into my own hands now.” So, with assistance from friends and family, she traveled to her mountain cabin, determined to stay until she either recovered or died.
Her recovery began almost immediately. At first, all she wanted to do was sleep, day and night. “It was,” she said later, “as if I was dead most of the time. Except that when I woke up, it was to the peace and silence, the clean water and the cold fresh air. It made me sleep deeper than I had in months. And when I was awake—oh, the beauty. I felt as if I was living in a Mary Oliver poem. I could open my windows and see the glowing green mountains, hear the nearby brook, feel the soft light of the moon at night. Everything changed by the minute. Animals, small and large, crossed my view. Rain and sun moved over me—alternating fire and water. The wind rippled through the trees. They seemed to be in constant prayer.” Friends and an assistant helped her eat, bathe, dress, and go outside. For two weeks, other than beholding beauty, her physical condition did not change. And then it did.
It was not a sudden, miraculous improvement. It was slow and incremental, like the waxing and waning of the moon. A little different each day. A bit more energy. A bit less pain. After two more weeks, she was able to go out on the back porch herself. In four weeks, she could walk for thirty yards to the stream behind her house. In six weeks, she ventured into the local town—with help. In eight weeks, she went there on her own. Also on her own, she gradually reduced her medications. Her pain pills, her antidepressants, her steroids. She hoped she would not relapse when she did this—and she did not. After three months in the mountains, Clara woke up one morning, got out of bed, and fixed a cup of coffee before she realized that she had not yet thought of her illness. That is when she knew she was solidly on the path to recovery.
Other things in her life also came together during those three months: the realization that she truly loved her family and wanted to spend more time with them; a clear view of the toll that her sacrifice for others—first teaching and then community service—had taken on her; a deep appreciation for being able to physically move and exercise, which was something she had never liked before. She had a deeper love for her body, as flawed and dysfunctional as it often was. When she returned home, she found that taking care of herself emotionally, physically, and spiritually was no longer an annoying chore, but a privilege—no, a necessity—for her life.
Several years later, Clara confessed to me, “I don’t know why I got sick. I had no more understanding of my illness than the doctors had. But I do know that I recovered by doing what I loved most. And in the process, I became more myself—more whole—than I had ever been before.” It was a profound and meaningful change in place and space that started Clara on the path to that wholeness—and to healing.
OPTIMAL HEALING ENVIRONMENTS
“Since the beginning of humankind,” writes architect Marc Schweitzer, who analyzed data on the effects of environmental design on health, “it is likely that people have been seeking safe shelter in which to heal.” Making simple changes in space can improve healing, function, and well-being inside and outside health care—in homes, worksites, and schools. Patients assigned to a room with a view recovered a full day faster after an operation, and two and a half days faster if hospitalized for mental health problems. Premature babies exposed to full-spectrum light that cycles like daylight gain weight faster than those exposed to continuous light—even though they have literally never seen the light of day. Student
s in classrooms with windows that open progressed 7% to 8% faster on standardized tests in one year than students in rooms with windows that could not be opened. Children allowed outside to play during school hours have fewer behavioral problems and do better in school, including on tests. Richard Louv, in his book Last Child in the Woods, summarizes the remarkable impact that exposure to nature (or lack of such exposure) has on children’s health, functioning, and happiness. (The book is a must-read for parents and teachers.)
An increasing number of hospitals around the country are now becoming the OHEs I introduced earlier. Samueli Institute, the organization I directed for fifteen years, created a model to measure whether a health care setting was impacting healing, not just curing. We showed that specific architectural elements—including lighting and interior design—can reduce stress and anxiety, increase patient satisfaction, improve morale and performance of health care workers, and promote the health and healing of patients. OHEs don’t just enhance well-being and improve clinical outcomes—they also save money.
Our definition of an OHE is a system and place designed to stimulate and support the inherent healing and wellness capacities of its inhabitants. In short, an OHE delivers healing-oriented practices and environments (HOPE) in a way that integrates them with medical disease treatments. I will show you how I use HOPE later, but for now, simply know that an OHE is a holistic organizing framework applicable to all health care organizations and health care systems. Consistent with its preventive and palliative role, it is also applicable in schools, worksites, and community locations. It is a way of connecting many models of care that share similar goals and philosophies—models such as relationship-centered care, patient-centered care, family-centered care, holistic care, integrative medicine, and the medical home, as well as worksite wellness and optimal learning environments. I briefly describe the OHE in the following section. More detail can be found on my website, DrWayneJonas.com.
THE FOUR DOMAINS OF AN OPTIMAL HEALING ENVIRONMENT
Note that these domains of an OHE parallel the dimensions of a whole person that Dr. Manu drew on his whiteboard in India (see this page) and also those that whole systems science identified as elemental for how people remain healthy and recover when ill—body, behavior, social, and spiritual. There are four OHE domains as well—internal, interpersonal, behavioral, and external.
Internal Domain
Healing intention: This is a conscious determination to improve the health of another person or oneself. It incorporates the expectation of an improvement in well-being, the hope that a desired health goal can be achieved, the understanding of the personal meaning that is attached to illness and suffering, and the belief that healing and well-being will occur.
Personal wholeness: This is the experience of well-being that occurs when the body, mind, and spirit are congruent and harmonious. Personal wholeness can be developed and fostered with mind-body practices that reinforce wellness and recovery.
Interpersonal Domain
Healing relationships: These are the social and professional interactions that foster a sense of belonging, well-being, and coherence. Nurturing healing relationships is one of the most powerful ways to stimulate, support, and maintain wellness and recovery.
Healing organizations: An organization’s structure and culture is important for implementing and maintaining an optimal healing environment. The vision and mission of an organization contributes to the development of a healing culture. A successful OHE organization also has a strategic plan for meeting goals, as well as leadership support, stable funding, and a flexible, resilient evaluative culture.
Behavioral Domain
Healthy lifestyles: Healthy behaviors can enhance well-being and can prevent, treat, or even cure many diseases. Making appropriate dietary choices, engaging in physical exercise and relaxation activities, and managing addiction are important to lifelong health and wellness.
Collaborative medicine: This is team-based care that is both person focused and family centered. It also includes thoughtfully blending the best of complementary therapies with conventional medicine.
External Domain
Healing spaces: These are built environments designed to optimize and improve the quality of care, outcomes, and experiences of patients and staff. Design components that foster wellness and recovery include evidence-based architectural design, color choices, and access to nature, music, art, and light.
When working with hospitals to use the OHE model, I often find it easiest to start with the external domain and then link it to the other domains. Many hospitals are now putting healing design into action. Next time you seek out a hospital or clinic or ask your insurance plan about coverage, ask if they provide or are becoming an OHE.
HOW TO BRING HEALING HOME
When I assist patients in discovering their own healing capacities, I always ask questions about where they live, work, learn, and play. Exploring these elements with patients helps them find and create the proper physical healing space—the space that their body dimension occupies.
While each of the elements in this bodily external dimension has evidence for its value, the purpose of exploring these is to find just a few—or even one—that is the most meaningful for them. We are seeking how to connect the external space they are in to the patient’s inner space of mental, emotional, and spiritual response. Susan would change her bedroom to simplify and sooth her sleep and ease care for her grandchild. Clara changed her location to soak herself in nature. Both used the external environment as an entry point to induce a meaning response for them and pave their path to healing.
Many healing traditions pay attention to space. In my research group’s global studies, we found traditions such as feng shui were used at the Great Wall Hospital for Xiao, and sthapatya ved, the ancient healing architecture of India, used at the ayurvedic hospital where Aadi was treated. In some Native American belief systems, “sacred geometry” assigns specific healing properties and meanings to each of the compass directions. Greek temples surrounded patients with nature, music, and art to restore harmony and promote healing. Florence Nightingale attributed differences in the survival rates of patients to differences in crowding, light, and ventilation. And unbeknownst to Clara, she was engaging in an ancient Japanese practice called shinrin-yoku, or “forest bathing.” Research has shown that immersing oneself in nature influences the body through more ways than simply the beauty and calm, as important as those are. Trees also emit chemicals called phytoncides that stimulate the immune system, something Clara likely needed. Being in nature also lowers cortisol and reduces heart rate and blood pressure. It increases our brains’ natural painkillers. Phytoncides allowed Clara to rest more deeply and experience less pain.
Most people are so familiar with the places they live that they no longer take note of the details of the space or its impact on their lives. However, when I ask them to tell me the ideal environment that evokes a positive memory of joy, awe, or beauty—their ideal place—they can almost always tell me. Is there a window from which to gaze out at nature? What are the colors of the walls and furniture that they love the most? Is there clutter to step over or move aside to get past? What attracts them to a place? Are there elements of a place that allow them to look beyond a chaotic, disorganized space to an image that brings peace and a smile? Most people know their own healing space when they see or imagine it. It is easy to tell when someone realizes his or her healing space—the face lightens, the breath deepens, the muscles release. The signs of a healing response become evident in the person’s posture and demeanor. My neuroscience mind sees my patient’s hippocampus integrating sensory cues of the place the patient is in with the emotional cues that produce relaxing and joyful memories. The patient reacts as if she were settling into her mother’s arms, like she has found a home. I then know she has connected her external environment to the inner dimensions of her life—social, emotional, mental, and spiritual—in a meaningful way. If she can make that a perm
anent space in her life, she more easily taps into the 80% of healing capacity that routine health care leaves largely untouched.
THE BEDROOM
When Susan came out of the operating room after her port placement, she knew how to solve her dilemma. She’d had an insight that she could use our bedroom as a healing sanctuary to recover from the chemotherapy and surgery and also to have a place where our grandson could be with her and play—with help, of course—during the most difficult times. She had never felt our bedroom had been a comfortable place to sleep—it was too cluttered inside and too open to the outside elements through a large French door and palladium window on one wall. And the colors were not right—too dark in some places and too bright in others. It did not feel like a calming, safe place to rest and bring a baby into. So of all the elements in her external dimension, it was the bedroom that Susan found most meaningful for her as she faced cancer and its treatment again.