We are for the most part more lonely when we go abroad among men than when we stay in our chambers. I would rather sit on a pumpkin and have it to myself than be crowded on a velvet cushion. Henry David Thoreau
Thoreau extolled the virtues of solitude in his book Waiden. He wrote about the joys of being alone and expressed sorrow for those who must always spend their time with others. How unhappy he would have been in our current day institutions for the elderly I Although privacy is a basic human need, there is little opportunity in institutions for the elderly for meeting that need. Residents commonly sleep in multiple bed rooms and share dining, activity, and lounge areas with many others. The bathroom, a very private place for most Americans, is generally shared also. Under these circumstances a modicum of privacy becomes difficult if not impossible.
Much has been written about the long-term effects of living in a rigid institutional environment. These effects include erosion of personality, overdependence, automatic behavior, and loss of interest in the outside world.1 Those familiar with institutions for the elderly have observed depression, resignation, apathy, and withdrawal from social interaction in the behavior of many of the residents. Although lobbies and lounges frequently contain a number'of residents, close observation reveals few meaningful interpersonal contacts. Individuals may sit next to each other for hours and never converse. If they do speak to each other, it is often in a hostile and defensive manner.
Peter Townsend, a British sociologist, has described this aspect of institutional living well: "In the institution, people live communally with a minimum of privacy, and yet their relationships with each other are slender. Many subsist in a kind of defensive shell or isolation."2
It is ironic that one of the reasons our society uses to justify the need for institutions for the elderly is the prevention of social isolation for those who are unable to maintain social contact in their living situation. It is simply assumed by both families and professionals, and even the elderly themselves, that they will feel less isolated and alone if they live in an institution with others.
Much research remains to be done in identifying the precise factors responsible for the negative social effects of institutional living. One important area that has been identified is the physical environment. A relatively new discipline of study called social ecology is concerned with the interaction between the physical and social aspects of the environment and attempts to identify and develop optimum human milieus.3 Several major concepts studied by social ecologists h*ave direct implications for understanding how the physical environment of institutions contributes to the behavior of the elderly in homes for the aged and suggest possible interventions that might alleviate the negative effects. These concepts are privacy, personal space and territoriality, and crowding.
Privacy is a basic human need and has been identified as a right of the elderly. Westin has defined privacy as the right of the individual to decide what information about himself should be communicated to others and under what conditions. The individual determines when, how, and to what extent information about himself is communicated to others.4 There is much anecdotal evidence of the importance of privacy, and studies of individuals in ghettos, prisons, and other sorts of communal living have described the lack of privacy and its consequent frustration and tension. Westin describes four basic states of privacy: solitude, intimacy, anonymity, and reserve.
Solitude is the most complete state of privacy. It is a state of complete isolation from the visual observation of others, the individual is separated from the group. Where, in homes for the elderly, can a resident find solitude? Not many residents have a private room where they can retreat and be alone. They are with others most, if not all, of the time.
Intimacy is the second state of privacy and involves the individual acting as part of a small group or unit in order to achieve a close, relaxed, and frank relationship. Again, such interaction necessitates controlling visual and other types of sensory informational flow through the use of various barriers or environmental props so that the unit can be alone. Without intimacy a basic need for human contact cannot be met.5
Anonymity, the third state, allows the individual to "merge into the situational landscape" according to Westin. In this state, the individual can be in a public place but still be free from identification and close observation. To be aware of direct and deliberate observation in public is to lose the ease and relaxation often sought in such a setting.
The most subtle and complex state of privacy is reserve, the creation of a psychological barrier against unwanted intrusion. This state allows each person, even in the most intimate situations, not to reveal certain aspects of himself that are either too personal, shameful, or profane. In order for this to be functional, the barrier must be honored by others; the individual must claim it for himself and respect it in others. Reserve permits us to have psychological privacy when the physical surroundings or group settings do not permit solitude or anonymity.
The functions of privacy are personal autonomy, emotional release, self-evaluation, and protected communication.6 Autonomy is a sense of individual and conscious choice in which the person controls his environment, including his ability to have privacy when desired. It is threatened by those who intrude without discretion or feel that their casual or uninvited help compensates for the violation. Institutionalized elderly are constantly subjected to this sort of intrusion from staff who ignore even the most conventional social norms such as knocking at a closed door before entering a room. Emotional release and rest from the tensions of always being "on-stage" and required to play the role can be an important function of privacy.
Privacy affords the individual the opportunity for self-evaluation. One must be removed from the dayto-day events in order to integrate and assimilate the continuing stream of information he receives. In a state of solitude or withdrawal during reserve, the individual makes plans by interpreting this information and anticipating his subsequent behaviors.7 Everyone needs time for reflection, creative imagination, and integration of life experiences. Erikson and others have suggested that finding meaning in one's life is a crucial task of later life. Most institutions for the elderly are poorly suited for such reflective work.
Limited and protected communication serves two important needs for the individual. First, it permits one to share confidences and intimacies with trusted individuals and, second, it establishes a psychological distance when the individual desires it or it is required by normative role relationships.7
Privacy has many defensive aspects such as withdrawal, seclusion, and avoidance of interaction, but the positive aspects need to be emphasized here. Privacy permits us to observe and deal with ourselves without the distraction of others' input. It is privacy that permits us to attain self-understanding and self-identity.3
The concept of the psychological function of privacy as increasing the individual's freedom of choice in a particular situation is an important one for understanding the behavior of institutionalized elderly. It has been proposed that in any situational context, the individual attempts to organize his physical environment so that it maximizes his freedom of choice. Privacy does this by permitting the individual to feel free to behave in a particular manner or to increase his range of options by removing certain classes of social constraints. "The overall function of privacy thus is to increase the range of options open to the individual so that he can behave in ways appropriate to his particular purpose."7 This desired freedom of choice can be achieved through the control of what goes on in a defined area of physical space and thus leads to a discussion of the concept of territoriality.
Personal Space and Territoriality
In order to understand the impact of the physical environment on the elderly, one must consider the concepts of personal space and territoriality. Sommer defines personal space as "an area with invisible boundaries surrounding a person's body into which intruders may not come."8 A territory is a delimited space that an individual or group uses and defends as an exclusive preserve.9 Defense of territories hinges on visible boundaries and markers while defense of personal space is a matter of gesture, posture, and choosing a location that conveys a clear meaning to others. "In many situations these two factors are so entangled that one sees them as part of a single process-the defense of privacy-that involves fundamental questions of space usage and property rights."8
Territorial behavior is commonly exhibited in institutions for the elderly. The existence of favorite chairs or locations in the public areas of such institutions has been well documented by research and observation. Lipman in a study of 17 English old folks' homes found that over 90% of those who regularly sat in the public areas of these homes occupied the same chairs in the same positions each day.8 Both staff and residents recognize this "ownership" and assist in maintaining the individual's territorial rights. *
Aggressive behavior is not uncommon in defense of this space. I recall one elderly resident who was hit over the head with a stout, wooden cane by another resident who found him sitting in "her chair." It was interesting to note that though the offending resident had been in the home a long time, he always appeared somewhat confused and unaware of the territories of others. The aggressor, also a long-term resident, was alert, well oriented, and maintained her selfidentity; she had a territory and would willingly defend it. The other residents generally gave her a wide berth!
Invasion of personal space raises the individual's anxiety and can provoke aggressive or violent behavior. Individuals vary in the amount of personal space required to feel comfortable. Ethnic and personality differences are related to distances people prefer to place between themselves. There is evidence that persons prone to violence require a larger buffer zone than do nonviolent individuals, and males require more space than do most females.3 The definition of "own" territory and preferred distance between self and others appears to be an important correlate of emotional malfunctioning. Several studies have found differences in territoriality and spatial habit patterns of clinical and normal populations.10
There are spatial correlates of status levels and, conversely, social correlates of spatial positions.8 Those in positions of dominance in the social order possess more space and have greater mobility. The converse of this correlate can be observed in homes for the elderly where those who have private rooms are treated as though they belong to a higher social class. Staff and residents intrude less frequently on the territory of these residents unless invited.
The basic function of territoriality is to ensure that the individual (organism) has the required space needed to be free of physical discomfort or pain. In the functioning human more than just space to breathe and carry on normal physiological functioning is needed, however. There must be a space lar^e enough to permit the satisfaction of drives that are sociospatial in nature such as affiliation and achievement.7 Territoriality, regardless of how achieved and maintained, determines which individuals have access to physical settings that can meet their needs.
Territoriality is one means of establishing and maintaining a sense of personal identity. In conditions of social isolation, there is a gradual increase in territorial behavior with respect to areas and objects in the environment and a general pattern of social withdrawal.10 The definition and organization of various role relationships is dependent on territorial behavior.7 Only nurses and physicians have access to certain areas in institutions for the elderly. This control of specific territory and the role relationships between staff and residents are interrelated.
When our privacy and space needs are not achieved, we feel crowded. Crowding is not just a function of a certain population density but rather a psychological state associated with too little physical or psychological space, feelings of loss of control over interactions, and undesirable or excess contact with others.11 Research in the field of housing indicates that persons who live among a multitude of people restrict personal contact to a limited number and show relative indifference toward the majority.8 The constant stimuli and lack of privacy when one is always with others leads to irritability, weariness, and withdrawal.3 Cultural background and past living experiences will lead to variations in what individuals define as crowded. A person who is accustomed to large amounts of space will probably expect more space in any given setting than one who is accustomed to less space.
Dormitory residents exposed to excessive interactions with others or living in high-density dorms felt more withdrawn and behaved less cooperatively and in a less socially responsible manner.12 Social overload arises when the number of potential social interactions that involve or impinge on a person is so great that one's attention capacity is taxed. Other studies in dormitories, by Valins and Baun, showed that people assigned to suites of four to six people experienced less feelings of crowding than corridor residents required to share bathrooms and lounge areas.12 This was true even though the space per person for corridor residents was the same as for suite residents.
An important consideration in defining spatial and territorial invasion is whether the parties involved perceive one another as persons. A nonperson can not invade someone's personal space. Under conditions of crowding it is common for one person to react to another as an object or part of the background.8 Such reactions decrease the need for territorial behavior and aggressive emotions. Under crowded conditions, there are certain social norms for maintaining privacy such as averting one's eyes and ignoring the presence of others as substitutes for physical barriers. This limits unwanted intimacy.8 Both personal space and territoriality are mechanisms used to achieve the level of privacy we desire. By varying the signals that state our boundaries and communicate our degree of receptivity to personal interaction, we can encourage or discourage interactions with others.
Studies Related to Spatial Behavior and Privacy Needs
DeLong theorizes that the elderly require three functionally different spaces in their institutional set- tings: private, semiprivate/semipublic, and public. His preliminary research indicated the following spatial-behavioral relationships: (1) private rooms decrease aggression and increase cooperation among the elderly; and (2) semiprivate/ semipublic space decreases aggression and increases cooperation, participation, social awareness, and public behavior.13 In DeLong's studies, private room residents were less rigid in their public seating behavior. He believes this was because there was less need for establishing personal domain in the public or social spaces such as corridors and lounges.
An additional observation from DeLong's studies was for a space to be defined as social by the elderly, there had to be a direct link between personal space and that area. The social area needed to have public access as well. Lounges or sitting rooms at the end of corridors become public rather than social spaces.13
Lyman and sScott's taxonomy of four human territorial forms is similar to DeLong's classification of space requirements. They are: (1) public territories to which most persons have access; (2) home territories or areas that allow freedom of behavior and a sense of control and intimacy: (3) interaction territories where social gatherings may occur; and (4) body territories or anatomical space and the immediate surroundings. Three types of encroachment upon another's territory were identified by Lyman and Scott: (1) violation (or unwarranted use of territory); (2) invasion (or unsolicited crossing of a boundry); and (3) contamination (or making the territory impure).14 Residents of institutions are subjected to all three types of encroachment by both staff and other residents. A large, homogenous area that lacks barriers or lines of demarcation makes it difficult to mark out and defend individual territories. Small, welldefined areas are easier to defend.8 If an area cannot be defended against intruders, it is not considered a private territory or domain.
Studies on resident satisfaction with and desire for private rooms are not conclusive. While social scientists agree that privacy is important to morale and satisfaction, not all residents state a preference for single rooms. In one study, older community residents, middle-class institutional residents, and current single-room residents were more likely to prefer single rooms. The overall preference for single rooms of institutional residents who currently occupied multiple bed rooms was about 50%.15 One wonders if the residents of multibed rooms were concerned about financial cost of other arrangements or so accustomed to the situation that they could not imagine any change as being positive. Lawton, too, was puzzled by the high preference for shared rooms and interviewed some of the study subjects a second time under more reassuring conditions. Their responses remained unchanged. However, in a later study of residents in an institution that was building a new home with mostly private rooms, there was an overwhelming preference for a single room both before and after the move. Lawton concluded that the "existence of a real alternative may allow the clearer emergence of what appears to be a latent need for privacy."16 It appears likely that future cohorts of older people will place higher values on privacy and single rooms as families have become smaller and standards of living higher.
Research with young persons in mental hospitals found that occupants of single rooms actually engaged in more person-to-person transactions than did occupants of multibed rooms.15 It has been observed that multibed rooms in nursing homes frequentlynserve as a single room during the day with its use being rotated among occupants.
Residents in smaller homes for the elderly were found to be less isolated in terms of frequency of social contacts and made more friends within the home itself than did residents of larger homes. Aides in the smaller homes were more likely to develop companionship relationships with the residents.17
The arrangement of furniture within a room has implications for increasing social interactions and providing privacy in institutional settings. Anyone visiting institutions is struck by the straight-row arrangements of chairs which is so common. Such arrangements are not conducive to social interactions. Sommer's studies in territoriality show that side-by-side seating intended to accommodate several persons is frequently occupied by only one person.8 While this confers the benefit of privacy on the single occupant, it is a waste of space and does nothing to encourage social interaction.
Once adequate private space is provided, there needs to be properly furnished areas for social inter- acting. These areas should have casual, conversational dumpings of chairs. Tables can be used to provide natural settings for activity or just conversation. People seem to prefer that chairs have their backs to the wall or other physical barriers. This offers a sense <5f security and provides a better vantage point.18
Osmond, in his work with mental patients, has constructed a continuum of environmental settings. At one extreme is the sociofugal environment that discourages social contacts and the formation of interpersonal relationships. Railway stations and hotel lobbies are common examples. Sociopetal environments, which encourage social contacts and the development of interpersonal interaction, are frequently circular in form and generally small. Osmond favors building institutions in a radial design with bedrooms on the outer circumference and common areas in the middle.14 Hallways are eliminated in this pattern and there is direct access from the personal to the social space. Close face-to-face furniture arrangements are provided in the social setting. Sommer and Ross used Osmond's concept of spatial arrangement of furniture on a "model" geriatric ward. The change from a sociofugal to a sociopetal pattern more than doubled the number of conversations among the patients.19
A Conceptual Model
It is clear that there is a relationship between the physical and social aspects of the environment. In Michelson's "intersystems congruence" approach, the environment is viewed as not determining behavior itself but "as setting broad limits on the phenomena that can occur in a given setting."14 Other important limiting variables are the social, cultural, and personality systems. Based on this assumption, one can create a physical environment that is congruent with the goal of promotion of social interaction and alleviation of social isolation and withdrawal.
The most important qualities of the physical environment are the amount and arrangement of space. Lawton has suggested that the syndrome of institutionalization may include "social withdrawal as a substitute for loss of physical privacy."5 This response can certainly be seen in many institutions for the elderly. When unable to meet solitude and intimacy needs in the face of constantly being with a number of other people, reserve and anonymity remain the only available forms of privacy. Use of these privacy seeking behaviors permits the individual to have some psychological, if not physical, relief from the presence of others. When used excessively, these behaviors result in the social isolation and withdrawal noted by Lawton.
When space becomes scarce, the individual's behavior is constricted. Reactions to encroachments may take the form of aggressive defence, barrier erection, or communal isolation by way of idiosyncratic communications. 14 There are feelings of both psychological and physiological stress when there is perceived spatial inadequacy. If individuals are unable to leave in search of more personal space, they may attempt to withdraw from social interactions in order to obtain some relief.14 Many of the institutionalized elderly are unable to escape from the physical setting for even short periods. For these individuals, social withdrawal is the only solution when their environment does not provide adequate privacy and personal space.
Figure 1 is an attempt to conceptualize the process and resultant behavior that occurs when individuals have inadequate personal space. Since privacy and territoriality serve basic functions necessary for both physical and emotional health, there are negative effects on the individual when these needs are not adequately met. A sense of loss of personal control and choice and a weakened personal identity are two of the major effects. The resultant behavior may include apathy, withdrawal, and aggression.
Improving the Physical Environment of Institutions for the Elderly
The conceptual model suggests that negative behaviors can be at least partially prevented by the provision of adequate personal space in the physical environment. (It is important to note here, as was done earlier, that there are a number of social, cultural, and personality variables that effect the behavior also.) In order to create a milieu more congruent with social interaction, there needs to be widespread changes in the physical environment in many, if not most, of the institutions for the elderly. While lip-service is given to the need for privacy, the realities remain grim. Butler and Lewis in their 1973 book, Aging and Mental Health, stated that privacy and space to move are rights of the elderly, but then proceed to say that multipatient rooms should not exceed four persons and that there should be at least one toilet for every six persons.1 Woe to the person searching for solitude and a personal territory in such an environment!
The following are assumptions that have guided my thinking in describing a more optimum physical environment for institutionalized elderly:
1. The design and arrangement of bedrooms, common areas, and hallways can facilitate or inhibit social interaction.
2. The arrangement of furniture, such as chairs and tables, can facilitate or inhibit social interaction.
3. The size of the institution can effect social interactions.
4. There is a minimum amount of private living space necessary for optimum health and social adjustment.
5. High-density living areas restrict social interactions. There is generally less interaction in a double than in a single room.
6. Loneliness and alienation are more often found in settings that individuals perceive as crowded.
The following are specific suggestions for improving the physical environment of institutions for the elderly. These conditions would permit privacy, promote social interactions, and minimize feelings of crowding:
1. Limit the size of the homes and the number of residents. Large institutions could have a number of smaller homes or units that share central services. Additional study needs to be done to determine the optimum size for homes or units within institutions.
2. Provide for private rooms. Double rooms can be partitioned down the center and still be considered double for purposes of billing. If partitions are not possible, furniture, screens, or curtains should be used to create physical boundaries for a private territory.
3. Build suites in homes for the elderly. Bedrooms should be placed adjacent to a semiprivate area for social interactions of small groups. A dining area could be provided for suite residents.
4. Provide small dining areas for a limited number of residents. While dining alone is not the best eating situation, dining in a room with 50 or more should be reserved for public events, not everyday life.
5. Limit the size of lounges and sitting rooms and provide small, casual groupings of chairs. Remember that large areas distant from the bedrooms (home territory) are not social but public spaces.
6. Provide more private bathrooms. If bathrooms are shared, the doors should lock. Staff can use pass keys in case of an emergency. Privacy in the bathroom is important for proper physiologic as well as social functioning.
7. Teach all staff to honor the privacy of patients. The staff should assist residents in establishing a private space for periods of solitude. If private rooms are not available, other arrangements for periods of solitude and intimacy each day should be made in consultation with the individual resident.
8. Arrange chairs and other furniture to maximize feelings of security and privacy. In large rooms, chairs should back on a wall or other physical barrier. Long rows of chairs are not functional socially. Use tables, bookcases, or plants to create dividers in large areas.
The changes suggested are neither complex nor profound. Why then have so few institutions for the elderly provided such an environment? There are a number of institutional and social policies that prevent such changes. Social policy for the elderly has been primarily concerned with maintenance of basic needs such as food, housing, health, and minimum income. While privacy and personal space are recognized by social scientists as basic needs, they are generally viewed as a luxury by social policy planners. Programs that provide financial support for the elderly, such as medicare and state old age pensions, are considered a form of welfare in our society and welfare recipients are not provided luxuries. Unless our society accepts the premise that institutionalized elderly have the same rights as others in our society, regardless of their ability to pay, there will not be funds available for the provision of the optimum environment. In many instances it would not require additional cost to effect the suggested changes, just a different use or arrangement of space.
A major factor impeding such changes has been called "institutional sanctity."18 Those who have tried to make even such minor changes as moving chairs in a lounge have discovered that both residents and staff will not accept the change and move the chairs back to their original positions. Moos states that "the tendency of the environmental status quo to discourage innovations in design and the rearrangement of existing settings cannot be overemphasized."14 It seems that even the unusual and unpleasant becomes customary and therefore preferred. People used to the settings they occupy treat them as fixed even though often they can be changed. In addition, the internal geography of most homes for the elderly has been determined by the staff's needs rather than the residents'. The nursing and custodial staff arrange things that are neat and easy to clean and that provide for maximum ease of movement from place to place.
While only about 4% of our elderly live in institutions, that is approximately one million people.20 Our institutional and social policies must deal with both the physical and social elements if we are to succeed in making these institutions places to live rather than places for a withdrawn and socially isolated existance. The assumption that being with others will prevent loneliness and social isolation is not defensible. The physical environment can be a major inhibiting factor or a major facilitating force to social interaction.
- 1. Butler RN, Lewis MI: Aging and Mental Health: Positive Psychosocial Approaches. St Louis, CV Mosby, 1973, pp 223, 226.
- 2. Towsend P: The purpose of institutions. in Tibbets C, Donahue W (eds): Social and Psychological Aspects of Aging. New York, Columbia University Press, 1962, p 379.
- 3. Insel PM, Lindgren HC: Too Close for Comfort: The Psychology of Crowding. Englewood Cliffs, Prentice-Hall, 1978, pp xi. 26, 116, 122-125.
- 4. Pastalan LA: Privacy as an expression of human territoriality, in Pastalan LA, Carson DH (eds): Spatial Behavior of Older People. Ann Arbor, University of Michigan, 1970, p 89.
- 5. Lawton MP: Ecology and aging, in Pastalan LA, Carson DH(eds): Spatial Behavior of Older People. Ann Arbor, University of Michigan, 1970, p 47.
- 6. Westin AF: Privacy and Freedom. New York, Atheneum, 1967, p 32.
- 7. Proshansky HM, et al: Freedom of choice and behavior in a physical setting, in Wohlwill J, Carson D (eds): Environment and the Social Sciences: Perspectives and Applications. Washington, DC, American Psychological Association, 1972, pp 36, 37, 39.
- 8. Sommer R: Personal Space. Englewood Cliffs, Prentice-Hall, 1969, pp 17, 23, 26, 31, 37, 41, 45, 51, 56.
- 9. Altman I: Territorial behavior in humans: An analysis of the concept, in Pastalan LA, Carson DH(eds): Spatial Behavior of Older People. Ann Arbor, University of Michigan, 1970, p 4.
- 10. Altman I, Haythorn W: The ecology of isolated groups, in Moos RH, Insel PM (eds): Issues in Social Ecology Milieus. Palo Alto, National Press Books. 1974. pp 390. 405-406.
- 11. Altman I: Crowding: Historical and contemporary trends in crowding research, in Baum A, Epstein YM (eds): Human Response to Crowding. Hillsdale, Lawrence Erlbaum Associates. 1978, p 18.
- 12. Saegert S: High-density environments: Their personal and social consequences, in Baum A, Epstein YM(eds): Human Response to Crowding. Hillsdale, Lawrence Erlbaum Associates, 1978. pp 257, 262-263.
- 13. De Long AJ: The micro-spatial structure of the older person: Some implications of planning the social and spatial environment, in Pastalan LA, Carson DH(eds): Spatial Behavior of Older People. Ann Arbor. University of Michigan. 1970. pp 83-85.
- 14. Moos RH: The Human Context: Environmental Determinants of Behavior. New York. John Wiley and Sons, 1976, pp 111, 120, 161, 165.
- 15. Lawton MP: The impact of the environment on aging and behavior, in Birren JE. Schaie KW (eds): Handbook of the Psychology of Aging. New York, Von Nostrand Reinhold, 1977, p 295.
- 16. Lawton MP: Some beginnings of an ecological psychology of old age, in Wohlwill J, Carson D (eds): Environment and the Social Sciences: Perspectives and Applications. Washington, DC, American Psychological Association, 1972. p 119.
- 17. Lowenthal MF. Robinson B: Social networks and isolation, in Benstock RH, Shanas E (eds). New York. Von Nostrand Reinhold, 1976, p 448.
- 18. Sommer R: Small group ecology in institutions for the elderly, in Pastalan LA, Carson DH(eds): Spatial Behavior of Older People. Ann Arbor, University of Michigan, 1970, pp 29, 34.
- 19. Griffin WV, et al: The psychological aspects of the architectural environment: A review, in Moos RH, Insel PM (eds): Issues in Social Ecology. Palo Alto, National Press Books, 1974, p 224.
- 20. US Dept of HEW: Facts About Older Americans. Washington, DC, Government Printing Office. 1978.