In such situations, social interactions are often imposed and can occur at inconvenient times, which may have an adverse effect on individual frustration tolerance. This can lead to fewer or even improper social interactions (25). “Privacy” is defined as an individual’s ability to protect interpersonal space —often a very subjective concept. Interpersonal space is the space in which 2 or more people come into any type of interaction (26). When equally accessible to all parties, interpersonal space is thought to protect against stress and violence (27). Individual strategies for maintaining personal space depend on culture, room size, level of acquaintance, and other social and psychological variables (27). For example, the interpersonal space required by an American would be larger than that required by a Mediterranean person. Similarly, it tends to be smaller when we are with people we know well as opposed to when we are with strangers. As social density increases, an individual’s “control” over environment decreases, which is in turn associated with self-reported, behavioural, and biochemical indices of stress (23). As more people are forced to interact and share a communal space—as is the case on a crowded psychiatric ward—their privacy, the social density of the ward, and the control they have on their environment are easily disrupted. Consequently, patients experience increased stress levels, which then precipitates violence. Conversely, in environments where density, privacy, and control are in optimal balance, violence is less likely to occur. It has been proposed that stress can be reduced and privacy to patients can be ensured through such simple environmental strategies as allocating individual rooms to patients, preventing crowding, and matching the ward activities to the needs and capacities of patients (22). The role played by the architecture of acute-care psychiatric wards in the occurrence of violence needs to be examined because privacy, density, and control are factors that can be manipulated by paying attention to architecture.

Area 2: Violence and the Architecture of Acute-Care Psychiatric Wards

There is often a lack of communication between hospital architects, patients, and staff working on acute-care psychiatric wards. Consequently, the architects of psychiatric wards often overlook or underestimate the impact of density and the loss of patients’ privacy and control over their environment (28,29).

As a result, their design may partially contribute to the occurrence of violence, given the significant discrepancy between living conditions in the community and those of a psychiatric ward. Living conditions in most Western countries allow people to have a great degree of privacy, control, and personal living space to conduct activities. The patient on a psychiatric ward, on the other hand, is faced with sharing communal rooms, such as the kitchen and lounge, largely with strangers. These areas are often cramped already, and a high ward population may worsen the situation. Areas perceived to be private, such as bedrooms, are smaller, and there is less objective area that the patient can define as his or her own. Not only are patients objectively crowded, but they may also strongly experience subjective crowding in such high density situations, because they see more people around them and experience increased intrusion. A sense of frustration and anger are expected outcomes, especially when they feel that they have lost control over their environment. This situation can be easily reversed by paying attention to architectural principles that enhance the therapeutic environment (29). Such strategies include dedicating space for social interaction, clearly indicating a room’s intended use, making areas visually distinct so that the intended use of different parts can be delineated from their appearance, using colours to enhance activities and spaces, using various materials to provide different tactile and visual experiences, using lighting to help define space, and finally, making the spaces that have special meaning to patients stand out (28). Enhanced dialogue between architects and mental health professionals can enlist architecture as a therapeutic tool and reduce environmental stress, which in turn should lead to reduced violence on psychiatric wards.

Area 3: Violence and Social Organization of Acute-Care Psychiatric Wards

The impact of a different living environment becomes clearer when the ward’s social organization is considered. The emphasis on psychiatric wards is to socialize and to participate in activities, which increases intrusion upon the patient’s personal living area and activities.