Designing for Health: Post-traumatic Understanding
We concluded the first day of training with a combat exercise. Clint, playing the part of an enemy combatant, disappeared deep inside the derelict motel. I was completely helpless to slow my racing pulse or quiet my panting breaths. At that moment, I was as close as a civilian can come to experiencing the stresses of urban warfare. Clint and I were the only two people in the building, wielding nothing more than paintball guns. This was where my research on designing for veterans with post-traumatic stress disorder (PTSD) became real.
Veterans are an important and interesting demographic: they are ethnoculturally, socioeconomically, and geographically diverse, but at the same time are unified by the military's standardized training, which affects perception as well as emotional reactions. To get a better understanding of how a veteran perceives and reacts to their surroundings, I partnered with Corporal Clinton McMahan, U.S. Marine Corp veteran, from whom I received hands-on training of military observational techniques. We focused on methods used to identify threats in indoor and urban conditions, as these are the most common environments veterans will encounter upon their return to civilian life.
When I was working with Cpl. McMahan, we visited Safety Wolf Paintball, a motel that has been converted to a recreational combat sports facility. To add "character," the owner painted the walls with what look like bloody hand prints - an unsettling and highly complex, non-repetitive, pattern.
To a combat veteran, a walk down the corridor at Safety Wolf might be perceived as dangerous because the complex pattern could easily camouflage threats, and therefore must be examined carefully. The intentionally high level of visual complexity achieved here produces a high "cognitive load," requiring more energy and focus to distinguish what is important from what is not. While the pattern on the walls of Safety Wolf isn't something we'd likely see elsewhere, a multitude of switches, sensors, rails, moldings, textures, and colors could be equally consuming.
Considering a holistic picture of health, PTSD can be a complex problem, as it can involve a range of anxiety-related symptoms stemming from a traumatic event. Memories of traumatic events can be stored differently than typical memories. Specifically, trauma memories are often fragmented, non-verbal, and disjointed in time, but can be easily triggered by similar stimuli. For example, a veteran of the Vietnam War may hear the sound of a helicopter harmlessly surveying traffic conditions and suddenly feel or act as if their traumatic event is happening all over again.
All of the human body's biopsychosocial systems operate within the same organism; what one system uses, another cannot. Thus, the more energy we spend to cognitively process stimuli, the less energy we have for other necessary tasks that are a part of optimal functioning of our brain and body. With this in mind, designers can begin to facilitate psychological healing from PTSD by reducing the cognitive load of the environment.
Although PTSD is a difficult condition, it is not without hope. Most people who experience trauma do not develop PTSD; when it does develop, it can typically be overcome with psychotherapy for trauma-related symptoms. Dr. Edward Vega, a psychologist for the Department of Veterans Affairs, points out that cognitive-behavioral treatments for PTSD, such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), are very effective at helping individuals overcome the impact of trauma in their lives. "The common elements of the therapies that work best appear to be helping people to confront rather than avoid things that are predictably safe but make them anxious," says Vega. "They also help people to examine and challenge their own thinking about the traumas they have experienced, and how these events may have changed how they look at themselves, other people, and the world around them." Confronting the triggers of one's anxiety can be very taxing, but ongoing practice reduces the anxiety reaction over time.
The built environment alone cannot solve PTSD, but it can help. To illustrate environment's ability to impact psychological wellness, let's take another look at the corridor at Safety Wolf Paintball. With their intervention, the owner has effectively increased the cognitive load of that environment, which can be seen as appropriate for this building used for combat sports. At the opposite end of the spectrum, when considering a space for psychotherapy, we should aim to reduce the cognitive load.
It is important to differentiate between how the built environment and psychotherapy can cooperatively contribute to recovery. Reducing the cognitive load of an environment isn't intended to avoid confronting one's trigger, but to prevent the patient from becoming overwhelmed by an excessive quantity of stimuli or by being unnecessarily exposed, as exposure would ideally occur initially in a controlled, deliberate, and constructive manner. Dr. Vega sees many similarities between exercising for physical and mental health. "When you intend to stress muscles beyond their usual capacity, you should warm up first. Over time, this can make your body stronger and more capable for a wide variety of activities." Considering the use of tools, Dr. Vega says "well designed fitness equipment can help focus exertion to the targeted muscles, building strength efficiently. Similarly, a well-designed psychotherapy environment can help focus attention and energy in the right areas, with less wasted effort." A reduction in the cognitive load of a space where therapy occurs, and the entire procession to this space, allows more of the patient's energy and focus to be dedicated to the task at hand.
While this example focuses exclusively on visual cues, we know that stimuli detected by any of our senses can trigger excessive anxiety. We also know that, regardless of mental state, the cognitive load of our environment affects the amount of energy required to process it. A reduction of the cognitive load of one's surroundings has the potential to benefit anyone undergoing any taxing process, be it healing from a physical or psychological wound, or undergoing a personal or professional cognitive challenge.
As designers, it is within our power to create spaces that promote wellness on many levels. By examining the case of veterans with PTSD, we can begin to learn lessons applicable to any healing space and better understand how design can facilitate truly holistic wellness.
For more information on this topic, please read the full report (PDF) on designing for veterans with PTSD.
Matt Finn is an Atlanta based architect with Perkins+Will, since joining the firm in 2007. Matt works across all market sectors providing architectural, interior, urban design, programming and construction administration expertise in addition to lending his photographic and graphic design eye. He is a recipient of Perkins+Will's research grant program Innovation Incubator. Matt can be reached at firstname.lastname@example.org.
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3. McMahan, C. (2013, May 24). Interview by M. Finn. Immersive simulated training, Day 1.
4. National Institute of Mental Health. Anxiety Disorders. Retrieved August 2013, from http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
5. Nebraska Department of Veterans' Affairs. How common is PTSD?. Retrieved August 2013, from http://www.ptsd.ne.gov/what-is-ptsd.html.
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8. Vega, E. (2013, August 10). Interview by M. Finn. The role of environment in posttraumatic growth.
9. Vega, E. (2014, Feb - March). E-mail interview with M. Finn. Treatments and environment in posttraumatic growth.