Kathy Hathorn, Principal-in-Charge,
American Art Resources, Houston, TX, USA

A Paper Presented at The International Conference and Exhibition on Health Facility Planning, Design and Construction, April 22, 1996, San Antonio, Texas, USA

"Beauty is in the eye of the beholder." This old adage is probably no where more true than in the healing environment. But in this particular instance, beauty connotes far more than aesthetics and the beholder is a patient or loved one undergoing one of life's most frightening experiences.

We are all products of our environment. From the time we are very young, we are influenced by the cultural, educational, ethnic, and religious factors that form our identities as members of the global communities in which we live. This pre-conditioning shapes the way in which we respond to the world around us.

When we talk about the therapeutic value of art, what are we talking about? Is it the art itself alone or is it also the manner in which it is perceived by the beholder? I'm personally intrigued by how the experience of the art, in addition to the art itself, may or may not contribute to the patient's well-being.

For example, Roger Ulrich's research in Sweden and Janet Carpman's work at the University of Michigan have provided us with impressive evidence that patients respond more favorably to art with views of nature than to abstract art. Let's move to the next step and ask this question?

Is it the view of nature alone that produces the therapeutic effect or is it also the context in which the art is viewed? In other words, does the same piece of art have a therapeutic effect regardless of where it is placed in a hospital or who is looking at it?

Let's take this example: a patient, in the emergency room at a local hospital, waiting in a typical stark room. Now, being the compassionate, sensitive professionals that we all are here today, let's give him a picture to look at - let's say, a painting of water, rushing down a rocky stream in the beautiful Texas hill country near San Antonio. You can see how this image could offer positive distraction to the patient who before had nothing to do before but dwell on his fears. A therapeutic experience? Yes.

But what would happen though if we moved that same painting to the hospital's ultra-sound waiting room? It's still art with a view of nature, but this would be a very uncomfortable and very negative image for some patients whose procedures must be performed with full bladders.

Let's talk again about the ER patient in San Antonio and the hill country painting that was so geographically familiar and reassuring. What if we substituted a traditional painting of a barge on the Seine or the canals of Venice?

Would this change perhaps decrease the comfort level of the patient because of its foreign setting? Could it possibly raise instead of lower his anxiety level because it underscores the alien detachment of the high-tech world of medical technology? Even under the least threatening circumstances, a hospital is still an abnormal environment - unfamiliar and frightening. Many of us today use terms like "psychologically-supportive spaces," patient-focused design and empowerment - all concepts with the same goal in mind - to reduce stress, to give the patient more control over his environment, and perhaps facilitate a more positive medical outcome. My contention is that in choosing art to create a healing environment, we must focus on both the treatment and the one being treated, the illness and the patient. And if you do this, then much about art that offers therapeutic benefit is also culturally, educationally, ethnically and geographically familiar to that same patient.

What I would like to share with you today is how nine different hospitals have created healing environments through the art in their facilities and how the therapeutic value of the art is shaped by demographics as much as by color, subject matter or anything else inherent in the art itself.

These nine facilities include two heart hospitals in Texas serving elderly Hispanic clienteles, three children's hospitals with long-term care patients, three acute-care hospitals in sub-tropical locations, and a hospital in a foreign country.

At first blush, it seems like art for the hospitals in each group would be identical, but look at how different it actually is. Look at what it takes to create an environment therapeutically unique to the patients at each facility.

Keep in mind how cultural, educational, ethnic and geographical factors represented in the art work together. See how they create comfortable, familiar and reassuring experiences for the patients at the various facilities.

I think you'll be surprised at how little of the art for the identical type of project is actually interchangeable from a therapeutic standpoint.

The first two projects examined are two heart centers: both in Texas, both serving a large elderly Hispanic clientele. But because of demographics, look how differently the art is used to create a therapeutic environment for the same special patient population.

The McAllen Heart Hospital recently opened in McAllen, Texas, near the Gulf of Mexico on the US-Mexico border. The project is an 82,000-square-foot new facility with architecture and interior design by HDR's Dallas office. McAllen Heart is a new concept in that it is a free-standing cardiac specialty hospital. The facility is being marketed as a new way of delivering the finest medical care in a cost-conscious manner. Emphasis is on the most advanced technology available set in a streamlined, efficient contemporary facility.

The segment of the market that the hospital is targeting is a wealthy Mexican-national clientele - cultured, educated, and sophisticated. These are people who would more than likely otherwise choose to go to the prominent heart specialists in Houston's medical center for treatment. So the role of the art became to make the patient feel that he or she had made the right choice by staying at home.

We were faced with an interesting challenge in that the client had strong feelings about using contemporary imagery, even abstract art, as an image statement about the facility. Once again, there are a number of clinical studies with findings suggesting negative effects of abstract art on patients.

So, what we did to balance the mandate of the client and the needs of the patient was to use abstract art only in key public spaces - the lobby, main corridor and the administrative suite. Notice that even though the art is abstract, it has a subdued quality to it. As abstract art goes, there is nothing harsh or confrontational about it.

Art for the rest of the hospital including all patient areas was still contemporary, but representational and readable, with a sense of optimism running through it. We looked for happy, bright colorful pictures - tropical landscapes with blue skies, cheery pots of flowers, views of the bay - images with an almost childlike joy to them.

We used a lot of deep saturated colors - colors associated with the Mexican culture - trying to create an environment through the art that seemed familiar and grounded in reality. This was done with the hope once again that the art would in some way play a role in empowering the patient - in instilling that will to live that is so important in the treatment and recovery of heart patients.

Notice though that the colors are cool: blues, greens, teals - colors that tend to calm and relax instead of excite or tire the patient.

The Methodist Heart Center in Lubbock, Texas, is a part of Lubbock Methodist Hospital, an 865 bed facility that is the largest between the Mississippi River and Los Angeles. Set in plains of sparsely populated west Texas, its service area is very large. It encompasses 27 counties in Texas and eastern New Mexico.

The Heart Center is a 127,000 square foot new facility designed by Parkhill, Smith and Cooper in Lubbock. Like the patients at McAllen Heart, many patients at Methodist are elderly Hispanics. But unlike the clientele at McAllen, many of these patients are poor, living mostly in remote rural areas of the state.

And while their medical conditions are exactly the same as those being treated in McAllen, the art that we chose to speak to these patients is very different. Why? Because their socio-economic backgrounds are very different. Many of these patients are from working-class backgrounds. Many of them are uneducated. Some of these patients have been treated as second class much of their lives simply because of circumstances beyond their control.

The hospital was very concerned that these elderly hard-working people be treated with dignity and respect. The art draws upon familiar imagery of both Old Mexico and west Texas. While the interiors at McAllen Heart have a slick, contemporary feeling, the interiors of Methodist Heart have a soft, more residential feeling. In general, the art for McAllen is sophisticated; the art for Methodist, sentimental.

With respect to treatment, the nursing staff puts a great deal of emphasis on return to an active lifestyle. It was our attempt to echo that effort in the art through images like these: older people working and playing.

This was an important message to impart to an elderly spouse keeping vigil, hours on end, in a waiting room - reassurance that his or her loved one would once again lead a full, productive life.

Another goal of the nursing staff was to promote lifestyle changes and healthy living to patients with a lifetime of bad habits. We chose images from nature with full-spectrum color - sunshine, flowers, the beauty of the west Texas landscape. We also used images that suggest healthy recreation - ways of reducing stress, and images of the family whose support and love are so critical to the cardiac patient.

Just for comparison sake, I'd like to show you another art program that we did at Methodist for a new 60,00-square-foot free-standing medical conference center, adjacent to the heart center that we just looked at. Notice how different the art is for the two facilities on the same campus.

Unlike the heart center, this facility was not built to serve patients. All patient and community education meeting facilities are located in the main hospital. This beautiful conference center, with facilities to accommodate 500 people, was built to house both national and international medical meetings. As such, the interiors are very corporate in nature, as is the art collection. In this particular project, we were dealing with aesthetics alone. The collection is a showcase of original art by well-known artists living and working in Texas and the Southwest.

Yet in spite of the technical and academic merit of the work, however, it is easy to understand that these pieces would not be nearly as beneficial to the viewer if here or she were a patient in the heart center across the street.

Health Central was designed by HKS for the West Orange Hospital District, which is the county hospital for Ocoee, Florida, a suburb of Orlando.

The project itself is a 260,000-square-foot acute-care replacement facility and medical office building. This enlightened client had already bought into the architectural designer's concept of patient-focused design and had presented us a strikingly beautiful contemporary building set on a 56-acre campus surrounded by orange groves.

Interior spaces feature a 4-story atrium with a fountain, natural finishes throughout the building to add softness and textural interest, oversize windows for natural light, and 11-foot ceilings in patient-care areas.

From the standpoint of both its bold contemporary architecture and its cutting-edge medical technology, Health Central is a facility designed to meet the needs of healthcare in the 21st century. The challenge in building an art collection for this architecturally innovative facility was to provide art that was clinically appropriate for different patient populations while maintaining the design integrity of the project.

Our task was made easier by the fact that the facility is located in a very high growth area of the city. The hospital would be serving a predominantly young, upwardly mobile and educated clientele. This allowed us to use images that were both contemporary and sophisticated.

The medical office building is integrated architecturally into the same building as the hospital, with professional offices for medical specialties located on the same floor as the nursing units for those patients. This gave us an opportunity in the elevator lobbies and waiting areas to use art as a wayfinding tool, in addition to creating a positive visual message. For example, these are pieces located at the entrance to the OB and the pediatricians' suites.

Both the architect and the client were very interested in creating a healing environment instead of just building a hospital. The architect looked for the art to support his philosophy of creating a positive sensory experience for those using the facility.

The limbic system is the part of our brain that turns short-term memory into long-term memory. It etches indelibly sight, sounds and smells; especially those associated with extreme stress, into our permanent memory banks.

It's why you can remember how the nursing home smelled when you went to visit your grandfather when you were only a child. Or why you can spend a fortune for a week at an elegant resort and have only a vague impression of the picture in your room, and yet you can describe in amazing detail the art hanging in your dentist's or gynecologist's office.

Let's look at the positive sensory experience created in this project through the marriage of art and architecture.

There are over fifty 30-foot-tall palm trees used at the entrance of the building to soothe patients and visitors with "white" noise. They are mirrored in the art for the lobby, bringing the calming sounds of nature in.

Look at the quiet, hushed elegance of these pieces in the OB unit. Feel the warmth of the sunshine in this large painting in the main dining area. It invites you to take a few moments to relax and get away from the stress of the nursing unit or the care of a sick spouse or child.

Once again, back to this painting in the OB elevator lobby: the feeling of holding hands in the warm sunshine, the sand, smooth and cool to bare feet buried beneath it. The great and simple taste perhaps of a picnic brought to the beach. Or the smell of clean air, ocean breezes, a fragrant tropical bloom.

Moving from the Health Central project near Orlando, the art program for the Sylvester Comprehensive Cancer Center at the University of Miami varies greatly. On the surface one might assume that because both are in Florida that the art could be the same for each. Nothing could be farther from the truth. Why? Because the facilities had different set of demographics and were serving different special patient populations.

The project is a 117,000 square foot outpatient addition to the Sylvester Clinic, one of only 27 federally designated comprehensive cancer clinics in the United States, putting it in the same league as Sloane-Kettering, MD Anderson, etc.

Demographically, the clinic serves an older middle and lower-middle class clientele that is reflective of the population of Dade County and the surrounding counties that make up Sylvester's service area. These people are typically snow birds who have retired to the area and who now live modestly on fixed incomes.

While this is true of the typical patient, the facility is still part of the University of Miami which is proud of its tradition of seven decades as an institution of higher learning. The university itself is set in Coral Gables, the oldest and wealthiest part of Miami and home to much period architecture.

To accommodate both users, we rigidly segregated the art by style for non-patient versus patient areas of the facility. Art for non-patient areas such as administrative offices, conference rooms, and meeting rooms has a distinctly formal quality to it. The goal of the art program for these areas was image enhancement - reflecting the reputation of the university.

While they are handsome and appropriate in public spaces, these images would offer little in the way of therapeutic value in patient areas. In fact, I have a good friend - a healthcare interior designer who won a battle with cancer a few years back.

She told me a very touching story the other day. She said that after her surgery, she had a beautiful picture of a lily in her room. And she said that during her lengthy stay in the hospital, she grew to hate this perfectly beautiful piece of art that she had to look at every day. Why?

Because once she had seen it as a pretty picture, it had nothing more to offer her - no motivation, no path of escape, no empowerment. To her it had become a symbol of death and of funerals.

This may seem an extreme reaction, but research supports what my friend had only her heart and instinct to tell her.

In her published work, Yvonne Clearwater supports the theory that viewers respond most favorably to landscapes that are spatially open and that have a long focal distance. I have a strong personal belief from my own anecdotal experiences that this is true.

These types of images become a path of escape for the gravely ill patient who must contend for days on end with the picture hanging at the foot of his bed - or who would otherwise stare at a blank wall in a treatment area. I have a feeling that my friend would have felt differently about a picture of lilies if they had been part of garden filled with flowers, trees and sunshine.

For cancer patients and others receiving prolonged treatments for life-threating conditions, I'm convinced that art that is contemplative - art from which the viewer can draw more and more each time he looks at it - helps the patient in his struggle to develop a sense of emotional balance and empowerment. It becomes a means to self-knowledge.

It's also interesting to look at some types of images that are inappropriate for special patient populations. For example, you would not want to select art with yellow for cancer patients whose skin may be jaundiced. And while images of water can be relaxing, be sure that the image is static and uncluttered. Churning waves and busy patterns would be very uncomfortable to a patient who is nauseated from chemotherapy or radiation treatments.

The last facility that we're going to look at in a tropical location is Columbia Bay Area Medical Center in Corpus Christi, Texas. Architecture is by the Stichler Design Group and interior design, by Watkins Carter Hamilton. It opened in 1993 and was the first new hospital built by Columbia.

The facility itself is a 310,000-square-foot acute-care hospital, women's center, and medical office building.

The client stressed his belief that a hospital is a place of health and healing and that reducing stress is a major part of that healing process. To meet the client's mandate, the interior design team designed a hospital with a restful, resort-like interior, minimizing clinical overtones typically associated with a hospital.

With this backdrop, we created a tropical retreat through the art, transporting the viewer to a more pleasant place and a happier time in their lives - escapism for those to whom the hospital is an all too real experience.

Demographically, the population of Corpus Christi is approximately 50% Hispanic/ 50% Caucasian. In a theme popular and familiar to both segments of the community, the art is a fusion of images of the geographical riches of the Gulf of Mexico. It is less sophisticated than the contemporary and somewhat cerebral images in the Health Central facility in Orlando. The art is geared to appeal to the largely middle and lower-middle class clientele the hospital serves and is more like the art for the patient areas in the Sylvester Cancer Center.

In addition to the hospital, the facility houses a large Women's Center for both gynecological and obstetric patients. The director of the OB unit asked us if we could help her with an educational message in the art for her patients.

One of the problems in the community, which certainly isn't unique to this facility or to Corpus Christi, is a very young age of first delivery. The average age here is seventeen.

Mothers that young are still children themselves in many ways. So it becomes the task of the hospital to provide as much educational support for these young women as possible. To meet this need, the art reinforces maternal bonding, the role of the father, families playing together. Images of water also add a sense of serenity to the environment and symbolize of the source of life.

The next three projects are for children's hospitals. The first project is one completed in 1993 for the Shriner's Hospital for Crippled Children in Portland, Oregon. It was a 60,000-square-foot-renovation and two-floor addition including patient care units, family housing and administrative areas, and an auditorium.

When I first interviewed the administrator of the facility, she expressed her need to create an environment to deal with the daily issues of an orthopedic hospital: parents with children facing a life time confined to a wheelchair - the loss of a limb through accident or amputation - or even the uncertainty of life itself because of muscular dystrophy or some other catastrophic illness.

She spoke about her concern for her staff - trying to cope with high stress and high frustration levels and almost inevitable burnout. In essence, like other children's orthopedic hospitals, this is a place where dreams don't always come true.

Therefore, it was very important for the art to impart a sense of normalcy to kids and their families trying to cope with permanent disabilities.

Thus, focal art pieces, located in the main corridors, portray the physically challenged in the mainstream of life - the message that life can still be lived to the fullest.

This is a large commissioned work that we placed by the door leading to the rooftop playground. This piece is special to everybody at the hospital because it was done from a composite of photographs taken during one of the hospital's regular ski trips with patients to Mt. Hood. Look at how the art reinforces the idea that healthy living and success in life are goals attainable for all.

Child-life specialists are always looking for role models for their patients. We saw this as an opportunity in the artwork - reinforcing the idea that life isn't worse now, it's just different. These photographs of wheelchair athletes are a great source of inspiration to kids who are convinced that they'll never shoot another hoop or run another race.

The family and administrative areas offered a different opportunity. In these areas, we concentrated on images of parents comforting their children - images of parental love, which in itself is healing. In these areas we also used the opportunity to visually impart the message of the Shriner's organization - that they serve children from all walks of life, all races, religions, and nationalities, regardless of ability to pay.

Now let's look at some of the art for the patient units and the reasons behind our choices. Because of the severity of their illnesses or medical conditions, many of these kids are here for lengthy stays. And, of course, many are readmitted time after time. As you can imagine, depression is a common problem for these kids.

So, we chose whimsical age-specific images for the patient-care areas that have vibrant stimulating colors, a lot of pattern and detail and busyness - images that have a kinetic quality to them - with the hope that they could help bring up the energy levels and spirits of the kids.

Loma Linda University Children's Hospital in Loma Linda, California, is an 110,000 square-foot pediatric intensive care addition, with 66 new beds on cardiac and bone marrow units. NBBJ in San Francisco was responsible for both architecture and interior design.

With 275 beds, Loma Linda Children's Hospital is one of the largest children's hospital in the United States and enjoys an international reputation for cutting-edge medical procedures. The "Baby Fay" baboon heart transplant performed here made headlines around the world.

Loma Linda Children's Hospital is owned by the Seventh Day Adventist Church whose mission is to heal and to teach around the world - a beautiful, natural world that God has created for all mankind.

To portray the mission of the church in the architecture and interior design, NBBJ drew upon themes of nature and discovery. And in turn, these were the themes developed and supported in the art. These themes offer not only an opportunity for learning, but also an effective distraction from the clinical environment.

Art for public spaces crosses nations and generations. There are a large number of original photographs of children in native costume from around the world showing how we are so different and yet so very much alike as God's children.

Vintage photographs from the Eastman Kodak library are placed in other public areas. They are used as a reminder of the gentle and fragile nature not of children, but of childhood, and how we as adults need to protect and nurture children more today because of the fragmented and dangerous world that they live in.

In family waiting areas where brothers and sisters must frequently wait with parents, we attempted to create an environment through the art that is both educational and entertaining. These intricate textiles from South America not only portray life of an indigenous culture, but also are a great positive distraction for kids having to spend time waiting in a distinctly adult world of a hospital.

To underscore the owner's strong belief in education, we chose themes in the art for public spaces such as ecology, our national parks, endangered animals, friends of all kinds.

Like the patients at Shriners, the kids on these two heart and bone marrow units are here for extended periods of time. On the nursing units themselves, we wanted to use images with the message that a child is loved and is being taken care of, even when the parent can't always be there. This was accomplished with original photographs of animals seeming to possess human-like traits of humor, playfulness, love, family, and companionship. These images also made great wayfinding tools for the kids.

The art program for this project was divided into two phases: phase one, which is the art that you've just seen; and phase two, a wish list which includes some large and expensive commissioned pieces that the hospital hopes to acquire through donations. I'll show you a few of these pieces, and you can see how they too will support NBBJ's theme of nature and discovery.

These are the molds for casting three large bas reliefs for the lobby, and actually these three pieces have just been completed. Another item high on the wish list is a large audio-kinetic sculpture by George Rhodes. You may have seen his work at San Diego Children's or Akron Children's Hospital.

This is a study for a life-size bronze has been considered for the entrance of the hospital. Look at the symbolism of creation, the universality of childhood, and the natural world in which we all live. So you see, you can create the same message through the art regardless of the medium.

The last children's project that I'm going to show you is a children's psychiatric hospital in central Florida. It serves a very wealthy, discreet clientele and is affiliated with a university and medical school. It has a large population being treated for depression or anti-social behavior. There is also a large out-patient program for eating disorders and smaller program for sexual abuse and chemical dependency.

I always find working with psychiatric hospital projects; especially those for children, absolutely fascinating because there's so much that you can do therapeutically with the art.

As with other children's projects that you are seeing here today, the art for this project is age-specific and geographically familiar - once again, creating that comfort level that we talked about before. But let's examine some opportunities in art that are unique to psychiatric facilities.

Art in treatment areas can be used as a catalyst in a session between a counselor and a patient. It's often difficult for children to talk about painful issues in adult terms, especially when they deal with family matters. Instead of using figurative art, look at what you can do: What do we see? Obviously a little girl is playing tea party with her doggie. But look again and think how a counselor could use this image in a dialog with a patient.

Is that your mom and dad? Is daddy home to have dinner with you? What do you talk about at dinner? Is it fun?

Or consider this image. To us, it's just a silly kid picture that makes us laugh. But a counselor could easily begin a dialog with a young patient to explore his low self-esteem. Who's the big guy? Is this you or is this the guy in class that you said everybody likes? Why is the little guy wearing those glasses? So you see how it begins to unfold.

Consider the diagnosis when you choose the message. Children who are depressed and children who hyperactive and out of control need different styles of art to help motivate them toward the desired behavior. Look at how simple and static these images are. And how busy these are, in contrast.

A large part of treatment programs for kids is to stimulate positive behavior and attitudes. And this can be done through the art. In this particular instance, the art also becomes a control device for the nursing staff since many of these little rich kids would still probably rather have a poster of Snoop Doggy Dogg or Dennis Rodman.

We saw this image before used so effectively in the Shriners' hospital project. But consider it again in light of what we've just seen. It's far too real - too emotionally charged and too provocative for the psychiatric patient.

Let's go back to the first slides that we looked at today. You were probably surprised at what you saw. But in fact, these images are indeed appropriate in every respect for the patients at this hospital because we are no longer dealing with a western culture. Recently I have been asked to develop an art program for an expansion and renovation project at Al. Salama Hospital, Jeddah, Kingdom of Saudi Arabia. The 1.3 million-square foot project is being designed by Jonathan Bailey at RTKL's Dallas Health and Sciences office. It is the first hospital in the world built as a five-star property, providing separate facilities to treat VIP's and the royal family. It is, for all practical purposes, a palace of healing.

My role has been to research the culture and to create an art program founded upon and respectfully acknowledging the basic tenants of Muslim faith and belief.

When the facility is completed in 1997, the art collection will consist of nearly 2000 works, most of which will be original. Framing for the VIP and royal suites will be hand-carved 23-karat gold-leaf frames, in keeping with the environment that the patients are accustomed to.

Saudi Arabia is the origin of the Muslim faith and is today the most fundamentalist of Muslim countries. Therefore, the art for this project had to be correct in all cultural and religious aspects.

Images of animals were avoided in the art program because of the Muslin concept of idolatry. Still lifes did not contain images of wine or liquor bottles or even glasses, since Islam forbids the drinking of alcoholic beverages. Architectural images reflected Muslim architecture, rather than Western imagery. Any symbols of other religions were omitted from the collection.

Even the concept of color is Islam has been treated completely different from a project in the Western culture. In the Islamic tradition, color is looked at principally from a metaphysical point of view. In the Islamic system of four colors, the primary colors are red, yellow, blue and green.

Green is viewed in Islam as the superior of the four colors because it embodies all of the others. Yellow and blue make green, and the after-image of green is red. Green is a religious color. Its significance to the viewer is obvious, since religion in Islam is a way of life and not an option as it is in the West.

The connotation of black and white differs from the Judaic-Christian concept of good and evil. In Islam, white, the absence of color, is a symbol of purity and the rational intellect. It is the outer aspect of all being.

Black, which is made up of all colors, is a symbol of emotion and the hidden part of man. Black is the color of the iris of the eye, the window of the soul. "Black is the inner aspect of all being" and doesn't have the negative connotation that it has in the western world.

Geometric art is very popular in the Islamic culture. To the eye of the western patient, its message is cold and disturbing; to the Muslim patient, the message is inspiring because symbolically geometrics represent wholeness, perfection and mankind's spiritual unity. These are the shapes occurring in nature and made by God.

Even these monumental outdoor sculptures, proposed for the entrances to the facility, embody the Islamic belief in the Universal Soul as it is manifested . . . as the passive qualities of matter (fire, water, air and earth).

©1996 American Art Resources, All rights reserved