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May 5, 2011 | by I Advance Senior Care

Our goal: Home, not home-like

Judah L. Ronch

When we create environments for people to come and live in, we are creating much more than the physical surroundings. We are creating home. But many of the environment designs we work with, because they are large, impersonal, and difficult to navigate or traverse, all too often still communicate limited expectations and the sense that their inhabitants will only decline. This view of elders assumes that it is normal for them to solely become passive recipients of the beneficence of helpers who are perceived as being there to merely ease the decline.

The physical environment has a significant influence on the culture of the community by shaping the ways in which people interact. If we are aware of the culture we want the environment to sustain, then we can create a culture in which intimacy-privacy, familiarity, personalization-and meaning are fostered, and that will truly be home.

We have a difficult challenge-to overcome our historical tradition of what Erving Goffman, in his 1961 study, Asylums, called “total institutions.”1 In this classic work he catalogued the many institutions we have developed that separate certain individuals and groups from the rest of society. These institutions isolate different populations, but all operate such that:

  • all aspects of life are conducted in the same place under the same single authority;

  • people are required to do the same thing and are grouped in activities with people who are like each other and are treated alike;

  • all aspects of the day are tightly scheduled, with one activity leading to another at a prearranged time, and the whole sequence imposed from above by a series of explicit formal rulings and a body of authorities; and

  • all activities are employed according to a rational plan that is designed to fulfill the aims of the institution and its reason for existing.

It is noteworthy that Goffman observes that institutional cultures are not totally exclusive of what we see in the rest of society, but that they merely remove certain behavior opportunities such as for interaction and making choices. He borrows a term from Sommer called “disculturation.”2 In these highly regulated, ritualized, and isolating environments, disculturated elders no longer engage with life-they are instead removed from growth opportunities and become passive.

We should ask ourselves whether traditional environments for aging persons are still disculturating elders, and we must examine whether we are designing them in ways that abet that. It is still common practice to limit opportunities for engagement and choice and, therefore, unnecessarily discourage spontaneous behavior. Society and these environments still see the aged-especially the dependent aged-as being unable to benefit from environments that demonstrate that psychological, cognitive, intellectual, emotional, social, vocational, biological, and spiritual development is attainable. In other words, we may not be giving elders the opportunities to continue to grow and develop, to find meaning, and to feel ownership and a sense of home in our communities. We know this to be paramount and that is why person-centered environments are so important.

We do not see ourselves as running “total institutions,” of course. In fact, research demonstrates settings vary in their degree of “institutional totality.”3 Our challenge is to change environments so that through enlightened design, they present opportunities to act in ways that enhance personal experience and make meaning in life by fostering development and intimacy.

How can the built environment help to enable a cultural environment that truly feels like home? Offer the opportunity to personalize each living space to each individual, so that the rooms speak of who they are-most of us do this as a matter of course. But also we need to create a sense of ownership of the shared spaces. Can residents traverse the community when they want to? Do they have the authority to make decisions and to go places when it’s of interest to them to do so?

Ownership means that access is not limited, and that residents understand that their home is their own. We should encourage individual choice about coming and going as they please, dining when and with whom they want to, being able to interact with others with whom they share common interests. M. Powell Lawton wrote that “one should note that what is called the environment may be either a space, a physical structure, an object, an item of décor, another person, or the collective behavior of a number of people.”4 All of these taken together create home.

We must also follow our hearts to create home from humane behavior. Oliver Sacks recounts the story of a patient he called the Lost Mariner, a man named Jimmy whose dementia resulted in his constantly walking throughout the nursing home in which he lived.5 Sacks, Jimmy’s neurologist, tried many things to get Jimmy to stop his constant walking and engage in some of the activities at the home. Nothing worked. In desperation he wrote to Dr. A.R. Luria, the most eminent neurologist in the world at the time, and asked his advice. Luria’s response was to “do whatever your ingenuity and heart suggest.”6 Furthermore, Luria pointed out to Sacks that he worked in a “home” which gave him an advantage in reaching Jimmy.

Luria’s positive use of the word “home” as a place where Sacks could use his heart to reach Jimmy can inform our actions as well. We must remember that our communities are home to our residents, and should never be just a “homelike” environment. Luria didn’t suggest a therapy, he encouraged (the root is from the French word, couer, for heart) Sacks to use his feelings and creativity to give Jimmy shelter from the internal storm of his dementia. A human and humane response, more than one driven by institutional rules and authority, will be more successful in creating home.

When a person moves to a new community in old age, Kivnick7 observes that the person starts to revisit the crises of psychosocial development described by Erick Erikson, which begin with Basic Trust vs. Mistrust. Can our residents trust the environments we create? More importantly, can they trust the sense of mistrust that overcomes some of them when they feel they are losing the opportunity for autonomy and growth? We can create cultures that provide intimacy and shelter from the many storms within and without. The homes we build should not render people lonely and isolated, but rather be where people gain comfort from each other’s intimate presence.

Home, not home-like, is the mission of culture change.

Judah L. Ronch, PhD, is the Dean of and professor at the Erikson School, University of Maryland Baltimore County, which offers undergraduate and Master’s degrees in Management of Aging Services as well as online and live Executive Education programs and customized industry training. To contact Dr. Ronch, email

JudahRonch@UMBC.edu.

References

  1. Goffman E. Asylums: Essays on the social Situation of Mental Patients and Other Inmates. Garden City, NY:Anchor Books, 1961.
  2. Sommer R.Cited in Goffman, above
  3. Bennet R. The Meaning of Institutional Life. Gerontologist 1963; 3:117-25.
  4. Lawton MP. Environment and the needs satisfaction of the aging.In: Carstensen L, Edelstein B, eds. Handbook of Clinical Gerontology. New York:Pergamon Press; 1987:33-40.
  5. Sacks O. The Man Who Mistook His Wife for a Hat. NY:Summit Books, 1985.
  6. Luria AR.Cited in Sacks, above
  7. Kivnick HQ. Everyday mental health: A guide to assessing life strengths. Generations 1993; 1:13-20.

Long-Term Living 2011 May;60(5):16-17

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