Designing Relief: A Mixed-Methods Experiment to Inform Crisis Room Design and Intervention in Acute Psychiatric Care

Designing Relief: A Mixed-Methods Experiment to Inform Crisis Room Design and Intervention in Acute Psychiatric Care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Designing Relief: A Mixed-Methods Experiment to Inform Crisis Room Design and Intervention in Acute Psychiatric Care Leonie Ascone, Candelaria Mahlke, Nour Tawil, Larissa Samaan, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7076311/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jan, 2026 Read the published version in BMC Psychiatry → Version 1 posted 10 You are reading this latest preprint version Abstract Background: The design of psychiatric environments influences patient experience, especially in acute crisis settings where perception is altered and emotional vulnerability is heightened. This also applies to crisis rooms, which are often used for seclusion—a practice increasingly criticized for its psychological impact. While guidelines call for de-escalating designs, the perspectives of patients with lived experience of seclusion have rarely informed such efforts. Methods: This mixed-methods study explored how individuals with lived experience of psychiatric seclusion ( N =30) perceive different visual design elements in simulated crisis room settings. Participants viewed nine digitally rendered room scenarios that varied by wall design (various nature-themed images and cool, pale colors) and furniture form (curved vs. angular) vs. an empty white control room (psychiatric paradigm of no stimulation). They rated each room on perceived restorativeness, stress, liking, and overwhelm and answered qualitative questions about crisis rooms and needs. Results: Nature-themed wallpapers—especially an image depicting dunes and water—and blue and green walls, were rated as more restorative and less stressful than both the control and a beige-painted comparison room. Furniture form showed no significant effects. Qualitative responses emphasized the importance of calmness, orientation, positive social interactions, recreational activities, selfcare, and environmental control. Conclusions: Design interventions in psychiatric crisis rooms—particularly those incorporating natural wall imagery and color— improve both the aesthetic and, more importantly, the emotional experiences of patients. The study underscores the feasibility and value of participatory approaches in healthcare design, guiding the decisions needed to co-create spaces that promote better mental health. Trial registration: The study and main analyses were pre-registered 2024/08/22 at aspredicted.org (#187275) https://aspredicted.org/9ht9-ckwn.pdf acute psychiatry coercion architecture participation design biophilia qualitative research Figures Figure 1 Figure 2 Background Human perception and behavior are not merely situated in space—they are shaped by it. In both psychiatry and psychology, there is growing recognition of the role that built environments play in influencing emotional and cognitive states. This is particularly relevant in psychiatric contexts, where individuals often experience heightened vulnerability. In such settings, the spatial environment can either support or hinder recovery. The concept of “therapeutic landscapes,” coined by Gesler (1992) captures the idea that certain places possess healing potential, shaped by both built elements, the surrounding—often natural—environment, and social and symbolic elements. While originally used to describe culturally significant healing places, this notion has informed a broader understanding of how place and atmosphere contribute to health. In contrast, modern hospitals including psychiatric wards are designed for efficiency, surveillance, and risk management. These priorities, though necessary, frequently result in sterile and impersonal environments that may aggravate psychological distress. In psychiatric care, where perception is often altered and emotional sensitivity heightened, spatial design takes on particular importance. It is thus crucial to identify which environmental factors may reduce stress and promote recovery. Nature Exposure and Mental Health A substantial body of evidence highlights the salutogenic role of nature exposure. Interactions with natural environments—whether direct or indirect—are associated with a wide range of physiological and psychological benefits, including stress reduction, improved emotion regulation, enhanced mood, and cognitive restoration ( 2 – 5 ). Individuals with high baseline stress or diagnosed mental illness appear to benefit more, showing greater responses suggesting recovery following (even short) exposure ( 6 , 7 ). In psychiatric settings direct access to nature is often limited—especially under conditions of coercion or confinement. Nevertheless, indirect exposure through environmental design can still promote mental well-being. Window views of greenery and access to natural light have been linked to shorter hospital stays among psychiatric inpatients ( 8 ). A study in an acute psychiatric unit found that realistic nature imagery on walls led to significantly fewer incidents requiring pro re nata (PRN) medication for agitation and anxiety, compared to abstract or no artwork, and was associated with cost savings ( 9 ). This aligns with the concept of biophilia , introduced by Fromm (1964) and later expanded by Wilson ( 10 ) as an evolutionary hypothesis: the idea that humans have an innate affinity for nature. These ideas have been adopted in architectural discourse under the concept of biophilic design . This approach advocates for integrating nature elements—including light, air, water, greenery, animals, landscapes, and ecosystems—as well as nature representations including organic forms, materials, colors, and images into built spaces to promote health and well-being (see 11,12). A growing body of experimental research supports that viewing nature, even in image form, can lead to improved mental health outcomes. Experimental studies show that images of forests increase perceived relaxation and comfort, while scenes with water evoke stronger feelings of restoration and preference than both built and natural scenes without water ( 13 , 14 ). A systematic review confirms that nature imagery—whether in photographs, 3D renderings, or virtual reality—can promote relaxation and lower physiological stress markers compared to urban scenes ( 15 ). Neuroimaging research shows that natural scenes activate brain regions associated with positive emotions and cognitive rest, while requiring fewer attentional resources ( 16 – 20 ). Color and psychological functioning in (healthcare) design Color is a fundamental design element that shapes how individuals feel and behave within spaces. Colors are typically described by three attributes: hue (e.g., red, green), brightness (light to dark), and saturation (intensity). Color is a powerful design element that shapes perception, mood, and behavior. Specific hues are associated with distinct emotional and physiological responses: blue and green tones—typically considered “cool” colors—are repeatedly linked to calmness, stress reduction, and improved focus in different settings ( 21 , 22 ). Pale colors, in comparison to saturated colors, elicit relaxation and calmness ( 23 ). In healthcare contexts, warm colors like red and yellow tend to evoke higher arousal, while blue and green are repeatedly associated with reduced heart rate, lower stress, anxiety, or depression and greater visual comfort and serenity ( 24 – 27 ). Thus, incorporating cooler, pale color schemes, such as blue and green shades, into clinical environments may serve as a low-threshold intervention to support emotion regulation and reduce distress. Curved Forms in Healthcare Design Beyond color and content, form also plays a role in psychological responses to built environments. A consistent finding across experimental research is the human preference for curved over angular stimuli. This preference was reported using abstract shapes, everyday objects, art, and architecture ( 28 – 32 ). Architectural forms also affect behavior, with demonstrated links to approach-avoidance behavior using both explicit ( 33 , 34 ) and implicit ( 35 ) measures, with curvature linked to more approach and angularity to avoidance tendencies. Neuroimaging studies using functional magnetic resonance imaging reveal that sharp-angled objects activate brain areas linked to fear and arousal ( 36 ) while spaces with curvilinear features trigger regions associated with positive emotions ( 32 ). In interior design and healthcare architecture, curved furniture and organic room designs may thus help foster a sense of comfort and psychological safety, though this has been understudied in psychiatric contexts. Architectural challenges of acute and emergency psychiatry Designing acute psychiatric wards presents a fundamental tension: ensuring safety while supporting recovery. Historically, ward Rooms have emphasized containment and surveillance. However, growing evidence suggests that more human-centered, de-escalating spatial design can reduce the need for coercive interventions such as forced medication or mechanical restraints ( 37 , 38 ). Policy guidelines increasingly recommend architectural features that minimize psychological burden—including daylight access, calming environments, and personalized control of sensory stimuli ( 39 ). Despite these recommendations, the voices of those most affected—patients with experience of seclusion—have rarely shaped architectural or clinical design. Qualitative research highlights that seclusion is often perceived as traumatic and disempowering, akin to imprisonment while others report feelings of temporary safety (Lindgren, 2019). This ambiguity underscores the importance of participatory, empathetic design that considers lived experience. Yet implementing such approaches in existing facilities is challenging due to outdated infrastructure and high patient turnover. Remarkably, the perspectives of those most impacted—patients with experience of seclusion—have largely been absent from architectural and clinical design discourses. The present exploratory mixed-method study investigated how individuals with lived experience of isolation perceive simulated crisis rooms featuring different wall designs and furniture forms. Combining quantitative ratings and qualitative feedback, the study aims to inform future design of de-escalation rooms through a participatory, evidence-based approach. The explicit goals of the present study were: To investigate to what extent different design factors (furniture form, wall design/color, empty control room) in de-escalation rooms would result in differential ratings of overall (a) restorativeness, (b) stress, (c) liking, or (d) overwhelm concerning the room’s possible effects in a mental crisis, including ten three-dimensional computer-generated room designs (Rooms), To explore quantitatively, which room design was favored overall by patients to inform the future design of the de-escalation rooms, and To qualitatively assess patients' experiences of and their needs during seclusion. Methods The study was conducted between summer 2023 and autumn 2024 and approved by the local ethics committee (vote ID: LPEK-0560, 20 Nov 2022). The procedure and materials were reviewed with EmPeeRie, a local scientific board of individuals with lived psychiatric experience. Every participant provided written informed consent prior to participation. Six eligibility criteria were applied: participants had to ( 1 ) have experienced psychiatric seclusion at least once and recall the event clearly; ( 2 ) be aged 18 or older; ( 3 ) self-report emotional stability (with clinician input where needed); ( 4 ) show no severe formal thought disorders, mania, or strong negative symptoms; ( 5 ) have normal or corrected vision and no color blindness; and ( 6 ) be able to give informed consent. All participants were informed about the study’s aim to improve the acute ward environment. The researchers, who were not part of the treatment team, first obtained informed consent and collected sociodemographic data. Diagnoses and seclusion histories (frequency, timing, location) were retrieved from casefiles or self-reports. Participants then viewed nine randomized 3D-rendered room designs, each featuring either angular or curved furniture (randomly assigned between-subjects), and one empty control room (psychiatric paradigm of ‘lack of stimulation’). For each room, participants were asked to imagine themselves in a mental crisis and provide spontaneous verbal associations, which were written down and confirmed. Four rating scales followed: restorativeness, stress, liking, and overwhelm (each on a 0–6 Likert scale) per room design. After the rating session, participants completed a deck sorting task by ranking printed images of all ten rooms from most to least preferred. They were then asked to rate how well they could imagine being in crisis during the experiment (0–100% scale). Finally, participants responded to open-ended questions about their ideal crisis or retreat room: its features, personal needs, stressors, and what should be avoided. They were also encouraged to reflect freely on the concept of isolation rooms per se, including abolishing them altogether. All responses were noted and verified for accuracy. The (translated from German) questionnaire items can be found in the Supplementary Materials A (A_Supplementary_Materials_E-Wall-Uation_questionnaire.docx). Stimuli Out of ten total room designs (for an overview see Fig. 1 ), six included wallpapers with natural landscapes without any humans, built elements, or large, visible animals: ( 1 ) Pine Tree Forest, ( 2 ) Königsstuhl (Island of Rügen) at Baltic Sea (chalk cliff), ( 3 ) Oak Tree on a Meadow, ( 4 ) Dunes & Baltic Sea, ( 5 ) River running through Wilderness, and ( 6 ) Grass Field near Mountain with Waterfall. Images were commercially available wallpapers or high-resolution printable images to be able to later implement the preferred motives on the walls of the isolation rooms at our own psychiatric ward. Image selection was based on the ratings of six colleagues with backgrounds in (landscape) architecture, environmental neurosciences, geography, or psychotherapy, and a clinician (psychiatrist) who worked at the acute ward at the time of the assessment. Furthermore, three colored rooms were presented: with ( 7 ) green, ( 8 ) blue, and ( 9 ) beige wall design. A ( 10 ) white, empty room was created, reflecting the psychiatric paradigm of ‘lack of stimulation’. The nine natural landscape and colored room designs were additionally furnished – either (as per random group assignment of the participant) with a curved vs. angular seating arrangement (bean bag, table, and puff). The furniture was inspired by commercially available products designed specifically for high-risk psychiatric settings (Pineapple Contracts Ltd., UK). Experimental Setup The study was conducted in a neutral room at the psychiatric clinic. A projector image was displayed on a plain white wall. The projection size was approximately 134 × 75 inches (340 × 190 cm). A Sharp PG-D2870W projector (3000 lumens, 1280x800 resolution) was used, chosen for its brightness over alternative models that were tested (LG PF1500G-GL, Epson H479B). To assure optimal quality of the projection, light absorbing curtains were closed for the simulated rooms rating sessions. Room designs were presented in a random order using Inquisit Player 6 (millisecond) on an ASUS Republic of Gamers laptop running Windows 10. Statistical Analyses The study and main analyses were pre-registered 2024/08/22 at aspredicted.org (#187275) https://aspredicted.org/9ht9-ckwn.pdf . The first research question was whether design factors of crisis room result in differential patient ratings concerning restorativeness, stress, liking, and overwhelm. A factorial design was employed with furniture form (angular vs. curved) as randomly assigned between-subjects factor and wall design as within-subjects factor ( N = 10, n = 6 furnished rooms with natural landscape wallpapers, n = 3 furnished rooms with natural wall colors [green, blue, beige], and the same room but empty with white walls [control]). Interactions between form and wall design were analyzed using repeated-measures mixed ANOVA in SPSS 27. Post-hoc tests to identify best-rated images were run using Wilcoxon signed rank tests, with resulting p -levels being adjusted for multiple testing using Benjamini-Hochberg- false discovery rate (FDR) correction ( 41 ). Qualitative Analyses To address the research question “How should crisis rooms be designed to adequately support patients' needs?”, qualitative data from the final open-ended questions (for details, see Supplementary Materials A) were analyzed. Participants were asked to describe their ideal crisis or retreat room and their needs, including desired features, treatment, stressors, and unacceptable elements. The term “isolation room” was deliberately avoided to encourage open responses. The goal was to stimulate participants’ imagination beyond traditional isolation room concepts, considering alternative models where rooms serve as voluntary retreat spaces rather than forced confinement. Data were analyzed by NB in a first round and refined by CM in a second round, using inductive category formation following Kuckartz ( 42 ), which allows categories to emerge from the data itself, following five iterative steps: Defining the purpose of category formation – determining what research questions the categories should address and considering prior knowledge. Determining category type and level of abstraction – deciding whether categories are factual (e.g., professions), thematic (e.g., climate change), evaluative (e.g., intensity of an emotion), or analytical (derived through deeper data interpretation). Familiarizing with the data and defining coding units – reviewing all responses and deciding whether to segment data into independent, self-contained meaning units. Iterative coding process – reading through responses sequentially, assigning existing categories or forming new ones, and refining the system as needed. Systematizing and structuring categories – organizing similar categories into main and subcategories, ensuring a clear and manageable coding system, and counting frequencies of mentioning across participants per (sub-)category. Through this process, common themes and needs regarding the design of crisis and retreat rooms were identified, offering valuable insights for improving psychiatric ward environments. Results Sample Thirty participants were recruited ( n = 14 female, n = 16 male). Mean age was 40.3 years ( SD = 13.5; range 22 to 74 years). Approximately 67% of patients had an ICD-10 F2 diagnosis (schizophrenia spectrum or delusional disorders), and 30% had an F3 diagnosis (affective disorders, mostly bipolar disorder). One patient (3%) was diagnosed with F1 (substance use), one with F4 (PTSD), and one with F6 (borderline personality disorder), one had missing diagnosis data. Concerning frequency of past isolation, patients reported two on average ( M = 2.2, SD = 2.83, range: 1 to 15), with most patients (80%; n = 24) knowing the isolation rooms due to previous experience at our ward. Since exact dates of the last seclusion experience were often not known, we compared the year of the experiment with the reported year of the most recent seclusion. Four patients had missing data on the most recent seclusion. For most participants ( n = 19; 73%), the last isolation experience occurred in the same year or the year prior to study participation. In five cases, 3 to 8 years elapsed, in four cases, the time elapsed exceeded ten years. Despite this variation, all participants confirmed that they remembered the isolation experience and related room clearly, often due to its emotionally impactful nature. Two patients had no school degree (~7%), two the lowest possible one in Germany (~7%), four a medium (~13%), and the majority ( n = 14, 57%) the highest attainable German school degree (57%). Five patients had missing data on education. Design effects on ratings of restorativeness, stress, liking, and overwhelm Further statistical details can be found in the Supplementary Materials B Excel file (B_Supplementary_Materials_descriptives_post_hocs_room_designs.xlsx). The between-subjects effect of furniture form (angular vs. curved) was not significant for any variable, with restorativeness (F(1, 28) = .047, p = .829, η²partial = .002), stress (F(1, 28) = 1.451, p = .239, η²partial = .049), liking (F(1, 28) = 0.035, p = .853, η²partial = .001), and overwhelm (F(1, 27) = 0.382, p = .542, η²partial = .014) all showing no significant differences based on furniture shape. However, means and SDs were in the expected direction, with higher ratings for curved furniture design rooms concerning restorativeness and liking, and higher ratings for angular design concerning stress and overwhelm (restorativeness: Mean angular = 3.52, SD angular = 1.93, Mean curved = 3.70, SD curved = 1.97; Liking: Mean angular = 3.37, SD angular = 1.97, Mean curved = 3.65, SD curved = 1.93; Stress: Mean angular = 2.30, SD angular = 2.00, Mean curved = 2.15, SD curved = 2.10; Overwhelm: Mean angular = 2.33, SD angular = 2.11, Mean curved = 2.18, SD curved = 2.22). A strong main effect of room design was found for all four dependent variables. Wall design significantly influenced ratings of restorativeness (Wilks' Lambda = .272, F(9, 20) = 5.961, p < .001, η²partial = .728), stress (Wilks' Lambda = .236, F(9, 20) = 7.201, p < .001, η²partial = .764), liking (Wilks' Lambda = .103, F(9, 20) = 19.296, p < .001, η²partial = .897), and overwhelm (Wilks' Lambda = .412, F(9, 19) = 3.009, p = .021, η²partial = .588). Interaction effects between Wall design and furniture form did not reach statistical significance for any of the variables—restorativeness (Wilks' Lambda = .855, F(9, 20) = .378, p = .932, η²partial = .145), stress (Wilks' Lambda = .727, F(9, 20) = .834, p = .594, η²partial = .273), liking (Wilks' Lambda = .674, F(9, 20) = 1.075, p = .422, η²partial = .326), and overwhelm (Wilks' Lambda = .705, F(9, 19) = 0.884, p = .556, η²partial = .295). Overall, these findings indicate that wall design had a strong significant effect on patients' ratings of restorativeness, stress, liking, and overwhelm, whereas furniture form did not significantly influence evaluations. Favored Room Design by Patients The post-hoc Wilcoxon signed-rank tests revealed significant differences between specific room / wall designs across all rating dimensions (for details, see Appendix I). Figure 3 depicts mean ratings, SDs, and significant differences found across rating dimensions and room designs. Additional details can be found in the Supplementary Materials B excel file. Restorativeness. All designed rooms were rated significantly more restorative than the control room (all p FDR < .02 ). Among the designed rooms, Room 9 (beige walls) was rated as significantly less restorative compared to Room 8 (blue wall) ( p FDR = .014 ) and Room 7 (green wall) ( p FDR = .029 ). Additionally, Room 5 (river running through wilderness) was perceived as significantly less restorative than Room 4 (dunes & Baltic Sea) ( p FDR = .046 ) and Room 8 (blue wall) ( p FDR < .05 ). Stress. All designed rooms were rated as significantly less stressful than the control room ( all p FDR < .04 ). Among the designed rooms, Room 9 (beige/grey walls) was perceived as significantly more stressful than Room 8 (blue wall) ( p FDR = .032 ). Additionally, Room 5 (river running through wilderness) was rated as significantly more stressful than both Room 4 (dunes & Baltic Sea) ( p FDR = .013 ) and Room 8 (blue wall) ( p FDR = .036 ), closely resembling the findings for restorativeness ratings. Liking. All designed rooms were rated as significantly more liked than the control room ( all p FDR < .01 ). Among the designed rooms, Room 9 (beige/grey walls) was liked significantly less than Room 8 (blue wall) ( p FDR = .007 ), Room 4 (dunes & Baltic Sea) ( p FDR = .039 ), and Room 7 (green wall) ( p FDR = .036 ). Additionally, Room 5 (river running through wilderness) was liked significantly less than Room 4 (dunes & Baltic Sea) ( p FDR = .039 ) and Room 1 (pine tree forest wallpaper) ( p FDR = .038 ). Overwhelm. The control room (C0) was perceived as significantly more disturbing than Room 8 (blue wall) ( p FDR = .019 ) and Room 7 (green wall) ( p_adj = .031 ) but did not differ from any other designed rooms. Card Sorting (Overall Ranking). The ranking task revealed that all designed rooms were preferred significantly more often than the control room (all p FDR < .01). Among the designed rooms, Room 8 (blue wall), Room 7 (green wall), and Room 4 (dunes & Baltic Sea) were most consistently ranked higher than the control and also outperformed other designs. Specifically, Room 9 (beige wall) was ranked significantly lower than Rooms 7 and 8 (both pFDR < .002), as well as Room 4 (pFDR = .0015) (for details, see Supplementary Materials B excel file). The findings suggest that room design strongly influenced perceptions of restorativeness, stress, liking, and overwhelm, whereas the control room consistently performed the worst across all dimensions, except for overwhelm. To summarize, the Dunes & Baltic Sea nature motive (Room 4), blue (Room 8) and green walls (Room 7) were consistently rated as the most restorative, least stressful, and most liked – even compared to the beige wall furnished room condition (Room 10). Additionally, blue and green walls were perceived as least overwhelming. Qualitative data analysis The content analysis of participant responses ( N = 30) revealed eight key thematic categories, with 17 subcategories related to experiences and needs regarding crisis rooms in mental healthcare settings. These categories emerged through systematic coding and analysis of participant statements and are reported with frequency counts (n) and an anchor example of a participant reference ( IDs ). Contact and Communication. The category contact and communication ( n = 26), comprises three distinct subcategories. Codes in the first subcategory “general contact” ( n = 12) express the need for regular contact, human interaction, and the need for visitor access (keep contact with the outside world ID2, Allow for family contact ID26) . The subcategory “staff contact” ( n = 6) has specific recommendations for accessibility to staff, highlighting the crucial role of consistent staff presence, particularly during critical situations like physical restraint ( staff needs to be there, especially during fixation ID 10 ). “Contact accessibility” ( n = 7) emerged as the third subcategory, stressing the need for a reliable response system and naming practical solutions for a quick access to staff, like call intercoms (staff should be there or quick to call e.g. call button ID 06) Therapeutic approach. The category therapeutic approach ( n = 28) includes three subcategories. “Handling and understanding needs” (n=8) refers to transparency about the situation, therapeutic support, and debriefing afterwards. Staff should be calm and qualified to handle acute situations and have knowledge of the patients’ individual needs and conditions. Participants suggested tools like mood cards to express emotional states. The need for respectful treatment and avoiding perceptions of inferiority was expressed ( not to be seen as dumb or less worth, be treated on eye-level ID 25). Codes in the second subcategory “restrictive and coercive measures” ( n = 14) express concerns about the use of coercive measures (use of physical restraint shouldn’t be as it is, it should be an exception ID 07). Participants questioned the philosophy behind restrictive measures, advocating for humane approaches, open-door policies, and alternatives to strong sedation. Numerous participants emphasized that visual reminders of former violence and coercive measures should be avoided, expressing the potential of triggering negative emotions (traces of violence are burdensome and scary, I get even more panic ID 09). Recommendations were to hide fixation straps, grids and cameras indicating a threatening environment. The last subcategory “basic care” ( n = 9) highlights the need for food and drinks during isolation, as well as access to running water, like a tab and a toilet flush. Recreational activity. The category “recreational activity” ( n = 31) reflects the need for appropriate occupational activities during seclusion, with the three subcategories “recreational opportunities” ( n = 9), “access to technical devices” ( n = 12), and “physical activity” ( n = 10). In the first subcategory, participants emphasized the overall importance of safe recreational options like books, arts supplies or fixed installations. In the second subcategory, specific suggestions included physical exercise equipment, meditation applications, yoga possibilities, and wall-mounted punching bags ( ID30 ). Technical solutions to listen to music, podcasts or radio, as well as access to mobile phones and a TV were mentioned by several participants in the last subcategory (radio, human voices ID 11). The data indicated a clear preference for activities that could serve both recreational and therapeutic purposes. Orientation. The category orientation ( n = 12) related to temporal and situational orientation. Participants emphasized the need for basic temporal awareness and spatial orientation through clocks and access to windows with a view to the outside. Participants expressed their need for transparent, early and clear information about their situation, including written documentation about their diagnosis, treatment status, and scheduled staff visits, as well as names and pictures of the staff, specifically the responsible physician ( Openness of information: Explain the patient what is currently happening and under what conditions they can leave again, as well as the truth about their situation ID 27). Room design. The subcategory “room design” ( n = 17) includes codes that subsume the need for a simple, calm and soothing environment, soft features and not too many stimuli, but with assemblance to a ‘normal room’. Provision of calming auditory stimuli (e.g., nature sounds, soothing music) and the incorporation of aromatherapy or scented elements, besides fresh air were recommended. A sufficient room size, to not to feel constricted and have enough space for physical activity, was mentioned as crucial. The subcategory “doors and windows” ( n = 14) highlights the wish for the possibility to view outside and fresh air and ventilation, besides being able to open the window themselves. Furthermore, the wish for an open door was expressed by several participants. The most frequent subcategory “light” ( n = 13) emphasizes the importance of adjustable lighting and jalousies, preferencing a warm and decent light that can be turned off ( Lights must not be on all night - it is best to decide for yourself ID 08) . The subcategory “wall design” ( n = 28) indicates preferences for coloring and wall visuals. Warm and soft colors, particularly blue and green, are frequently mentioned, and wall visuals compared to blank walls are commonly preferred. Participants mention nature motifs, especially those featuring the ocean, water, or dunes and to avoid overwhelming details or overly intricate visuals. Some patients express the preference for not covering the entire wall (Maybe only partially painted, allowing patients to choose where to rest their gaze ID 06) . In the subcategory “furnishing and décor” ( n = 33), codes indicate a preference for a furnished room with décor features specifying covers, cushions, carpets, and real plants. Most mentioned is the need for a comfortable bed with bedclothes and cover and an opportunity to sit, like chairs and sofa, with some also naming a table and a closet (bed and clean sheets; without a bed there is no real possibility to rest [in the current condition] ID 27 ) Hygiene. The last category hygiene consists of the subcategories “hygiene standards” ( n = 9) and “sanitary arrangements” ( n = 10). Codes include references to poor existing hygiene standards and highlight the importance of a clean and hygienic environment in seclusion rooms. Multiple recommendations to regularly clean the room, including the use of disinfection and the availability of personal sanitary products like toothbrush and paste, soap, and toilet paper are made. Codes express the need for usable sanitary facilities with a door, containing several mentions of a flushable toilet and a comfortable, non-steel, toilet seat (Cleanliness is super important! ID14) Discussion Our findings contribute to the broader research on psychiatric ward design by demonstrating that wall design may influence patients’ perceptions of restorativeness, stress, liking, and overwhelm. Specifically, nature-themed designs, especially blue and green colors, as well as a water-themed visual (Dunes & Baltic Sea) were consistently rated as more restorative and likable, while stress and overwhelm ratings were highest for the control condition (empty room with blank walls). Importantly, this study was not only about evaluating specific designs but also about co-developing multi-method approaches for shared decision-making with patients with lived experiences of confinement or seclusion. By engaging patient boards and individuals with lived experience in the process through structured ratings and open questions, we implemented a feasible approach to collaboratively and systematically assess preferences and needs. This participatory approach allowed us to identify design preferences directly linked to subjective well-being during mental health crises. It also underscores a critical gap in current architectural and clinical design practices, where patients are rarely consulted despite being primarily influenced by related choices. Our findings align with existing guidelines and evidence supporting biophilic (ward) design principles ( 11 , 38 ) and extend this work by identifying water-associated imagery and cool natural colors low in saturation as particularly well-received. On the other hand, our data provide no evidence that furniture form—curved vs. angular—affects patients’ emotional or cognitive responses in a statistically significant way, even though prior research had suggested such effects (e.g., 34,35). This discrepancy may stem from the limited salience of form manipulation in our projected settings, and/ or lack of power due to low sample size. Moreover, the qualitative responses highlight that participants not only evaluated aesthetics but also reflected deeply on their experience of isolation. Comments reiterate that patients desire spaces and related social interactions that offer comfort, autonomy, and a sense of control—needs that are rarely met in conventional psychiatric isolation rooms. Patients repeatedly emphasized the importance of light, fresh air, cleanliness, and the ability to orient themselves in time and space. Several participants expressed that a well-designed room might have helped them regulate their emotions better. The demands for better ventilation and adapted lighting and temperature conditions are underpinned by Bramesfeld et al. ( 39 ) guidelines from Germany. Several participants wished that the doors should not be locked, as reported in previous studies ( 43 ) Furthermore, no signs of coercive practice and violence should be visible in the isolation rooms. A recent study showed that perceived coercion is linked to higher PTSD and lower treatment satisfaction and that combined coercive measures negatively impact functionality improvement and increase re-admission risk ( 44 )). Cameras in isolation rooms were criticized by several participants. In discussion with our co-author and peer support specialist MF, it became clear that the issue is not surveillance per se, but a lack of social reciprocity: to feel seen without having the opportunity to see back —to engage, orient, or connect. This asymmetry can intensify feelings of objectification, powerlessness, and isolation. Constant personal observation is rather mandatory, at least during restraint ( 45 ), which aligns with participants’ wishes of constant staff contact and would obsolete video observation. Bramesfeld et al. ( 39 ) also emphasize the desire for autonomy, similarly reflected in this sample. Our results show a strong wish for self-directed activity, social contact initiation, and opportunities for selfcare, as well as being able to regulate the room conditions accordingly (e.g. light, windows, doors, water, hygiene). Overall, these findings suggest a complex interplay of needs during coercive measures, emphasizing the importance of maintaining human dignity through appropriate contact, environmental conditions, and meaningful activity options. The results indicate that while safety remains paramount, the implementation of coercive measures as last resort should consider these various aspects to potentially reduce negative experiences and support recovery. This insight dovetails with broader debates on the ethics and efficacy of coercion in psychiatry. Isolation, while sometimes deemed necessary, is experienced by many as traumatizing and disempowering ( 40 ). Architectural decisions that mitigate this experience should therefore not be viewed as "soft" design aspects but as integral to a rights-based and recovery-oriented approach to care. Our study shows that patients are not only willing but are also able to contribute meaningfully to such re-design efforts when given the opportunity. Limitations Despite its promising findings, this study has several limitations. The sample size was small ( N = 30) and skewed toward individuals with higher levels of education. The timing of the last isolation experiences varied considerably, albeit most participants had undergone coercion within the last one to two years, reporting vivid memories in general. Additionally, the visual stimuli focused solely on wall design and furniture, whilst other relevant spatial features such as lighting, brightness, sound, temperature, or other spatial design aspects were omitted. This reductionist approach was necessary to ensure cognitive accessibility and feasibility for our patient population but may limit ecological validity, which could be achieved by implementing (multimodal) Virtual Reality (VR) paradigms. Furthermore, in addition to subjective ratings, it would be recommendable to assess objective responses to the designs, such as via physiological arousal (electrodermal activity, heart rate, etc.). Concerning the qualitative study part, it can be criticized that no in-depth interviews were conducted, and verbatim content was not recorded (e.g., using audio equipment), while relying on notes (albeit those were validated and confirmed by participants). This approach was adopted to assure an acceptable time frame for the study including both quantitative and qualitative aspects (1-1.5 hours) and minimize participant burden. Current levels of patient distress or symptom severity were not systematically assessed. While experimenters perceived participants as sufficiently reliable, formal clinical assessments could strengthen future studies. Conclusion This mixed-methods study illustrates the potential of intentional visual design in psychiatric crisis rooms. Nature-inspired wall visuals—particularly those depicting a soothing ocean scene or calming cool (blue, green) colors—were associated with increased perceived restorativeness and reduced stress. Perhaps more importantly, the study demonstrates that patients with lived experience of seclusion are not only able to articulate nuanced preferences but should be actively involved in shaping healthcare environments they encounter during their most vulnerable moments. Future efforts to reduce coercion in psychiatry must extend beyond clinical protocols to include architectural and sensory dimensions—and above all, they must include those most affected at every step. Declarations Clinical Trial Number Clinical trial number: not applicable. Human Ethics and Consent to Participate The study was approved by the Ethics Committee of the Medical Chamber Hamburg (vote ID: LPEK-0560, approval date: 20 November 2022). All procedures were conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection. Author statement All authors agreed to the submission and publication of this manuscript. Data is available from the first author upon reasonable request. We have no competing or conflicting interests to declare. Competing interests The authors declare that they have no competing interests Funding This research was funded via a grant received by L. Ascone, provided by the Peter Beate Heller-Stiftung (project/ funding ID: T0160/40700/2022/kln). Availability of data and materials All relevant data and materials are available from the first author upon reasonable request. CRediT statement L. Ascone: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, writing – original draft, writing – review & editing C. Mahlke: conceptualization, data curation, formal analysis, methodology, writing – original draft, writing – review & editing N. Tawil: conceptualization, methodology, writing – original draft, writing – review & editing L. Samaan: conceptualization, methodology, writing – review & editing M. Frisch: conceptualization, investigation, methodology, writing – review & editing L. Nugent: conceptualization, methodology, writing – review & editing R. Nixdorf: conceptualization, methodology, writing – review & editing F. Börncke: conceptualization, methodology, writing – review & editing D. Lüdecke: conceptualization, methodology, writing – review & editing N. Bach: conceptualization, investigation, methodology, writing – review & editing C. Hackbarth: conceptualization, methodology, writing – review & editing T. McCall: conceptualization, methodology, writing – original draft, writing – review & editing J. Gallinat: conceptualization, methodology, writing – review & editing, supervision S. Kühn: conceptualization, funding acquisition, methodology, writing – review & editing References Gesler WM. Therapeutic landscapes: Medical issues in light of the new cultural geography. Social Sci Med 1 April. 1992;34(7):735–46. Bratman GN, Anderson CB, Berman MG, Cochran B, de Vries S, Flanders J. u. a. Nature and mental health: An ecosystem service perspective. Sci Adv 1 Juli. 2019;5(7):eaax0903. Hartig T, Mitchell R, De Vries S, Frumkin H. Nature and Health. Annu Rev Public Health 18 März. 2014;35(1):207–28. Markevych I, Schoierer J, Hartig T, Chudnovsky A, Hystad P, Dzhambov AM. u. a. Exploring pathways linking greenspace to health: Theoretical and methodological guidance. Environ Res Oktober. 2017;158:301–17. 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Chuquichambi EG, Corradi GB, Munar E, Rosselló-Mir J. When symmetric and curved visual contour meet intentional instructions: Hedonic value and preference. Q J Experimental Psychol September. 2021;74(9):1525–41. Silvia PJ, Barona CM. Do People Prefer Curved Objects? Angularity, Expertise, and Aesthetic Preference. Empir Stud Arts Januar. 2009;27(1):25–42. Tawil N, Ascone L, Kühn S. The contour effect: Differences in the aesthetic preference and stress response to photo-realistic living environments. Frontiers in Psychology [Internet]. 2022 [zitiert 1. Dezember 2022];13. Verfügbar unter: https://www.frontiersin.org/articles/ 10.3389/fpsyg.2022.933344 Vartanian O, Navarrete G, Chatterjee A, Fich LB, Leder H, Modroño C. u. a. Impact of contour on aesthetic judgments and approach-avoidance decisions in architecture. Proc Natl Acad Sci U S 18 Juni. 2013;110(Suppl 2):10446–53. Dazkir SS, Read MA. Furniture Forms and Their Influence on Our Emotional Responses Toward Interior Environments. Environ Behav September. 2012;44(5):722–32. Vartanian O, Navarrete G, Chatterjee A, Fich LB, Leder H, Modroño C. u. a. Preference for curvilinear contour in interior architectural spaces: Evidence from experts and nonexperts. Psychology of Aesthetics, Creativity, and the Arts. Februar. 2019;13(1):110–6. Tawil N, Elias J, Ascone L, Kühn S. The curvature effect: Approach-avoidance tendencies in response to interior design stimuli. J Environ Psychol Februar. 2024;93:102197. Bar M, Neta M. Visual elements of subjective preference modulate amygdala activation. Neuropsychologia. 2007;45(10):2191–200. Rohe T, Dresler T, Stuhlinger M, Weber M, Strittmatter T, Fallgatter AJ. Bauliche Modernisierungen in psychiatrischen Kliniken beeinflussen Zwangsmaßnahmen. Nervenarzt 1 Januar. 2017;88(1):70–7. Ulrich RS, Bogren L, Gardiner SK, Lundin S. Psychiatric ward design can reduce aggressive behavior. J Environ Psychol 1 Juni. 2018;57:53–66. Bramesfeld A, Dinter F, Meyer-Pfeffermann E, von den Benken G. Planungshilfe deeskalierende psychiatrische Akutstationen (Planning Guideline for De-escalating Psychiatric Acute Ward Design). Niedersächsisches Ministerium für Soziales, Gesundheit und Gleichstellung; 2021. Lindgren B, Ringnér A, Molin J, Graneheim UH. Patients’ experiences of isolation in psychiatric inpatient care: Insights from a meta-ethnographic study. Int J Mental Health Nurs Februar. 2019;28(1):7–21. Benjamini Y, Hochberg Y. Controlling the False Discovery Rate: A Practical and Powerful Approach to Multiple Testing. J Roy Stat Soc: Ser B (Methodol). 1995;57(1):289–300. Kuckartz U. Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterstützung. 4. Auflage. Weinheim; Basel: Beltz Juventa; 2018. (Grundlagentexte Methoden). El-Badri SM, Mellsop G. A study of the use of seclusion in an acute psychiatric service. Aust N Z J Psychiatry Juni. 2002;36(3):399–403. Herrera-Imbroda J, Carbonel-Aranda V, García-Illanes Y, Aguilera-Serrano C, Bordallo-Aragón A. García-Spínola E, u. a. An Exploratory Study about Factors and Outcomes Associated with the Experience of Coercive Measures in Mental Health Settings. Psychiatr Q März. 2025;96(1):133–44. Steinert T, Noorthoorn EO, Mulder CL. The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries. Front Public Health. 2014;2:141. Additional Declarations No competing interests reported. Supplementary Files BSupplementaryMaterialsdescriptivesposthocs.xlsx ASupplementaryMaterialsEWallUationquestionnaire.docx Cite Share Download PDF Status: Published Journal Publication published 16 Jan, 2026 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 01 Sep, 2025 Reviews received at journal 29 Aug, 2025 Reviews received at journal 10 Aug, 2025 Reviewers agreed at journal 06 Aug, 2025 Reviewers agreed at journal 06 Aug, 2025 Reviewers invited by journal 27 Jul, 2025 Editor assigned by journal 27 Jul, 2025 Editor invited by journal 18 Jul, 2025 Submission checks completed at journal 16 Jul, 2025 First submitted to journal 16 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":124894,"visible":true,"origin":"","legend":"\u003cp\u003eDesign stimuli of de-escalation/ acute rooms of the experiment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote.\u003c/strong\u003e The stimuli displayed as grey rectangles cannot be displayed here due to copyright, but hyperlinks for those images are provided. The six landscapes were: (1) Pine Tree Forest, (2) Königsstuhl (chalk cliff on the German Baltic Sea island ‘Rügen’), (3) Oak Tree on a Meadow, (4) Dunes \u0026amp; Baltic Sea, (5) River running through Wilderness, (6) Grass Field near Mountain with Waterfall. In all rooms (except for the control one), the seating arrangement in front of the main wall was varied to be either angular or curved (between participants), resulting in a total of n=10 stimuli per participant: 6 natural landscape motive walls + 3 colored walls + empty control room.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7076311/v1/b1c03513da317a5c5f339cf5.jpg"},{"id":88093771,"identity":"c3198923-621e-44ac-a6d5-7ae16f10ef79","added_by":"auto","created_at":"2025-08-01 10:42:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":72500,"visible":true,"origin":"","legend":"\u003cp\u003eAverage patient ratings per room ID (1–10) across four rating dimensions: restorativeness, stress, liking, and overwhelm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote. \u003c/strong\u003eSignificant differences between rooms are indicated by small numbers (indicating a significant difference to the respective Room design (1–10) above the respective bars). Error bars represent 95% confidence intervals around the mean. (1) Pine Tree Forest, (2) Königsstuhl (chalk cliff on the German Baltic Sea island ‘Rügen’), (3) Oak Tree on a Meadow, (4) Dunes \u0026amp; Baltic Sea, (5) River running through Wilderness, (6) Grass Field near Mountain with Waterfall, (7) Green Wall, (8) Blue Wall, (9) Beige Wall, (10) Neutral (white, empty) Control Room.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7076311/v1/1b74f97e3a646ab6ad9772c1.jpg"},{"id":100616181,"identity":"e03b9287-d2d7-4b68-b3ed-6017e9cd2f3b","added_by":"auto","created_at":"2026-01-19 17:41:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1068202,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7076311/v1/2cf5df3f-0272-4788-b1bf-ffbb5bc4962d.pdf"},{"id":88092628,"identity":"5847e997-b021-4b74-825f-320efae0b909","added_by":"auto","created_at":"2025-08-01 10:34:10","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":95297,"visible":true,"origin":"","legend":"","description":"","filename":"BSupplementaryMaterialsdescriptivesposthocs.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7076311/v1/907b648485c5bba2df6719a7.xlsx"},{"id":88092633,"identity":"185bf73a-46ee-47ad-b682-a043af3356b2","added_by":"auto","created_at":"2025-08-01 10:34:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":72195,"visible":true,"origin":"","legend":"","description":"","filename":"ASupplementaryMaterialsEWallUationquestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7076311/v1/12da9d38cdde62f603bc65c0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Designing Relief: A Mixed-Methods Experiment to Inform Crisis Room Design and Intervention in Acute Psychiatric Care","fulltext":[{"header":"Background","content":"\u003cp\u003eHuman perception and behavior are not merely situated in space—they are shaped by it. In both psychiatry and psychology, there is growing recognition of the role that built environments play in influencing emotional and cognitive states. This is particularly relevant in psychiatric contexts, where individuals often experience heightened vulnerability. In such settings, the spatial environment can either support or hinder recovery. The concept of “therapeutic landscapes,” coined by Gesler (1992) captures the idea that certain places possess healing potential, shaped by both built elements, the surrounding—often natural—environment, and social and symbolic elements. While originally used to describe culturally significant healing places, this notion has informed a broader understanding of how place and atmosphere contribute to health. In contrast, modern hospitals including psychiatric wards are designed for efficiency, surveillance, and risk management. These priorities, though necessary, frequently result in sterile and impersonal environments that may aggravate psychological distress. In psychiatric care, where perception is often altered and emotional sensitivity heightened, spatial design takes on particular importance. It is thus crucial to identify which environmental factors may reduce stress and promote recovery.\u003c/p\u003e\u003cp\u003e\u003cb\u003eNature Exposure and Mental Health\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA substantial body of evidence highlights the salutogenic role of nature exposure. Interactions with natural environments—whether direct or indirect—are associated with a wide range of physiological and psychological benefits, including stress reduction, improved emotion regulation, enhanced mood, and cognitive restoration (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Individuals with high baseline stress or diagnosed mental illness appear to benefit more, showing greater responses suggesting recovery following (even short) exposure (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In psychiatric settings direct access to nature is often limited—especially under conditions of coercion or confinement. Nevertheless, indirect exposure through environmental design can still promote mental well-being. Window views of greenery and access to natural light have been linked to shorter hospital stays among psychiatric inpatients (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A study in an acute psychiatric unit found that realistic nature imagery on walls led to significantly fewer incidents requiring pro re nata (PRN) medication for agitation and anxiety, compared to abstract or no artwork, and was associated with cost savings (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This aligns with the concept of \u003cem\u003ebiophilia\u003c/em\u003e, introduced by Fromm (1964) and later expanded by Wilson (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) as an evolutionary hypothesis: the idea that humans have an innate affinity for nature. These ideas have been adopted in architectural discourse under the concept of \u003cem\u003ebiophilic design\u003c/em\u003e. This approach advocates for integrating nature elements—including light, air, water, greenery, animals, landscapes, and ecosystems—as well as nature representations including organic forms, materials, colors, and images into built spaces to promote health and well-being (see 11,12).\u003c/p\u003e\u003cp\u003eA growing body of experimental research supports that viewing nature, even in image form, can lead to improved mental health outcomes. Experimental studies show that images of forests increase perceived relaxation and comfort, while scenes with water evoke stronger feelings of restoration and preference than both built and natural scenes without water (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A systematic review confirms that nature imagery—whether in photographs, 3D renderings, or virtual reality—can promote relaxation and lower physiological stress markers compared to urban scenes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Neuroimaging research shows that natural scenes activate brain regions associated with positive emotions and cognitive rest, while requiring fewer attentional resources (\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eColor and psychological functioning in (healthcare) design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eColor is a fundamental design element that shapes how individuals feel and behave within spaces. Colors are typically described by three attributes: hue (e.g., red, green), brightness (light to dark), and saturation (intensity). Color is a powerful design element that shapes perception, mood, and behavior. Specific hues are associated with distinct emotional and physiological responses: blue and green tones—typically considered “cool” colors—are repeatedly linked to calmness, stress reduction, and improved focus in different settings (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Pale colors, in comparison to saturated colors, elicit relaxation and calmness (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In healthcare contexts, warm colors like red and yellow tend to evoke higher arousal, while blue and green are repeatedly associated with reduced heart rate, lower stress, anxiety, or depression and greater visual comfort and serenity (\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e–\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Thus, incorporating cooler, pale color schemes, such as blue and green shades, into clinical environments may serve as a low-threshold intervention to support emotion regulation and reduce distress.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCurved Forms in Healthcare Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBeyond color and content, form also plays a role in psychological responses to built environments. A consistent finding across experimental research is the human preference for curved over angular stimuli. This preference was reported using abstract shapes, everyday objects, art, and architecture (\u003cspan additionalcitationids=\"CR29 CR30 CR31\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e–\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Architectural forms also affect behavior, with demonstrated links to approach-avoidance behavior using both explicit (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and implicit (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) measures, with curvature linked to more approach and angularity to avoidance tendencies. Neuroimaging studies using functional magnetic resonance imaging reveal that sharp-angled objects activate brain areas linked to fear and arousal (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) while spaces with curvilinear features trigger regions associated with positive emotions (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In interior design and healthcare architecture, curved furniture and organic room designs may thus help foster a sense of comfort and psychological safety, though this has been understudied in psychiatric contexts.\u003c/p\u003e\u003cp\u003e\u003cb\u003eArchitectural challenges of acute and emergency psychiatry\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDesigning acute psychiatric wards presents a fundamental tension: ensuring safety while supporting recovery. Historically, ward Rooms have emphasized containment and surveillance. However, growing evidence suggests that more human-centered, de-escalating spatial design can reduce the need for coercive interventions such as forced medication or mechanical restraints (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Policy guidelines increasingly recommend architectural features that minimize psychological burden—including daylight access, calming environments, and personalized control of sensory stimuli (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these recommendations, the voices of those most affected—patients with experience of seclusion—have rarely shaped architectural or clinical design. Qualitative research highlights that seclusion is often perceived as traumatic and disempowering, akin to imprisonment while others report feelings of temporary safety (Lindgren, 2019). This ambiguity underscores the importance of participatory, empathetic design that considers lived experience. Yet implementing such approaches in existing facilities is challenging due to outdated infrastructure and high patient turnover. Remarkably, the perspectives of those most impacted—patients with experience of seclusion—have largely been absent from architectural and clinical design discourses.\u003c/p\u003e\u003cp\u003eThe present exploratory mixed-method study investigated how individuals with lived experience of isolation perceive simulated crisis rooms featuring different wall designs and furniture forms. Combining quantitative ratings and qualitative feedback, the study aims to inform future design of de-escalation rooms through a participatory, evidence-based approach. The explicit goals of the present study were:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo investigate to what extent different design factors (furniture form, wall design/color, empty control room) in de-escalation rooms would result in differential ratings of overall (a) restorativeness, (b) stress, (c) liking, or (d) overwhelm concerning the room’s possible effects in a mental crisis, including ten three-dimensional computer-generated room designs (Rooms),\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo explore quantitatively, which room design was favored overall by patients to inform the future design of the de-escalation rooms, and\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo qualitatively assess patients' experiences of and their needs during seclusion.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study was conducted between summer 2023 and autumn 2024 and approved by the local ethics committee (vote ID: LPEK-0560, 20 Nov 2022). The procedure and materials were reviewed with EmPeeRie, a local scientific board of individuals with lived psychiatric experience. Every participant provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003eSix eligibility criteria were applied: participants had to (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) have experienced psychiatric seclusion at least once and recall the event clearly; (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) be aged 18 or older; (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) self-report emotional stability (with clinician input where needed); (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) show no severe formal thought disorders, mania, or strong negative symptoms; (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e) have normal or corrected vision and no color blindness; and (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e) be able to give informed consent. All participants were informed about the study\u0026rsquo;s aim to improve the acute ward environment. The researchers, who were not part of the treatment team, first obtained informed consent and collected sociodemographic data. Diagnoses and seclusion histories (frequency, timing, location) were retrieved from casefiles or self-reports. Participants then viewed nine randomized 3D-rendered room designs, each featuring either angular or curved furniture (randomly assigned between-subjects), and one empty control room (psychiatric paradigm of \u0026lsquo;lack of stimulation\u0026rsquo;). For each room, participants were asked to imagine themselves in a mental crisis and provide spontaneous verbal associations, which were written down and confirmed. Four rating scales followed: restorativeness, stress, liking, and overwhelm (each on a 0\u0026ndash;6 Likert scale) per room design. After the rating session, participants completed a deck sorting task by ranking printed images of all ten rooms from most to least preferred. They were then asked to rate how well they could imagine being in crisis during the experiment (0\u0026ndash;100% scale). Finally, participants responded to open-ended questions about their ideal crisis or retreat room: its features, personal needs, stressors, and what should be avoided. They were also encouraged to reflect freely on the concept of isolation rooms per se, including abolishing them altogether. All responses were noted and verified for accuracy. The (translated from German) questionnaire items can be found in the Supplementary Materials A (A_Supplementary_Materials_E-Wall-Uation_questionnaire.docx).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStimuli\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of ten total room designs (for an overview see Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), six included wallpapers with natural landscapes without any humans, built elements, or large, visible animals: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) Pine Tree Forest, (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) K\u0026ouml;nigsstuhl (Island of R\u0026uuml;gen) at Baltic Sea (chalk cliff), (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) Oak Tree on a Meadow, (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) Dunes \u0026amp; Baltic Sea, (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e) River running through Wilderness, and (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e) Grass Field near Mountain with Waterfall. Images were commercially available wallpapers or high-resolution printable images to be able to later implement the preferred motives on the walls of the isolation rooms at our own psychiatric ward. Image selection was based on the ratings of six colleagues with backgrounds in (landscape) architecture, environmental neurosciences, geography, or psychotherapy, and a clinician (psychiatrist) who worked at the acute ward at the time of the assessment. Furthermore, three colored rooms were presented: with (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e) green, (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e) blue, and (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e) beige wall design. A (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e) white, empty room was created, reflecting the psychiatric paradigm of \u0026lsquo;lack of stimulation\u0026rsquo;. The nine natural landscape and colored room designs were additionally furnished \u0026ndash; either (as per random group assignment of the participant) with a curved vs. angular seating arrangement (bean bag, table, and puff). The furniture was inspired by commercially available products designed specifically for high-risk psychiatric settings (Pineapple Contracts Ltd., UK).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExperimental Setup\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in a neutral room at the psychiatric clinic. A projector image was displayed on a plain white wall. The projection size was approximately 134 \u0026times; 75 inches (340 \u0026times; 190 cm). A Sharp PG-D2870W projector (3000 lumens, 1280x800 resolution) was used, chosen for its brightness over alternative models that were tested (LG PF1500G-GL, Epson H479B). To assure optimal quality of the projection, light absorbing curtains were closed for the simulated rooms rating sessions. Room designs were presented in a random order using Inquisit Player 6 (millisecond) on an ASUS Republic of Gamers laptop running Windows 10.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study and main analyses were pre-registered 2024/08/22 at aspredicted.org (#187275) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://aspredicted.org/9ht9-ckwn.pdf\u003c/span\u003e\u003c/span\u003e. The first research question was whether design factors of crisis room result in differential patient ratings concerning restorativeness, stress, liking, and overwhelm. A factorial design was employed with furniture form (angular vs. curved) as randomly assigned between-subjects factor and wall design as within-subjects factor (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6 furnished rooms with natural landscape wallpapers, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3 furnished rooms with natural wall colors [green, blue, beige], and the same room but empty with white walls [control]). Interactions between form and wall design were analyzed using repeated-measures mixed ANOVA in SPSS 27. Post-hoc tests to identify best-rated images were run using Wilcoxon signed rank tests, with resulting \u003cem\u003ep\u003c/em\u003e-levels being adjusted for multiple testing using Benjamini-Hochberg- false discovery rate (FDR) correction (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo address the research question \u0026ldquo;How should crisis rooms be designed to adequately support patients\u0026apos; needs?\u0026rdquo;, qualitative data from the final open-ended questions (for details, see Supplementary Materials A) were analyzed. Participants were asked to describe their ideal crisis or retreat room and their needs, including desired features, treatment, stressors, and unacceptable elements. The term \u0026ldquo;isolation room\u0026rdquo; was deliberately avoided to encourage open responses. The goal was to stimulate participants\u0026rsquo; imagination beyond traditional isolation room concepts, considering alternative models where rooms serve as voluntary retreat spaces rather than forced confinement. Data were analyzed by NB in a first round and refined by CM in a second round, using inductive category formation following Kuckartz (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e), which allows categories to emerge from the data itself, following five iterative steps:\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eDefining the purpose of category formation \u0026ndash; determining what research questions the categories should address and considering prior knowledge.\u003c/li\u003e\n \u003cli\u003eDetermining category type and level of abstraction \u0026ndash; deciding whether categories are factual (e.g., professions), thematic (e.g., climate change), evaluative (e.g., intensity of an emotion), or analytical (derived through deeper data interpretation).\u003c/li\u003e\n \u003cli\u003eFamiliarizing with the data and defining coding units \u0026ndash; reviewing all responses and deciding whether to segment data into independent, self-contained meaning units.\u003c/li\u003e\n \u003cli\u003eIterative coding process \u0026ndash; reading through responses sequentially, assigning existing categories or forming new ones, and refining the system as needed.\u003c/li\u003e\n \u003cli\u003eSystematizing and structuring categories \u0026ndash; organizing similar categories into main and subcategories, ensuring a clear and manageable coding system, and counting frequencies of mentioning across participants per (sub-)category.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThrough this process, common themes and needs regarding the design of crisis and retreat rooms were identified, offering valuable insights for improving psychiatric ward environments.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty participants were recruited (\u003cem\u003en\u003c/em\u003e = 14 female, \u003cem\u003en\u003c/em\u003e = 16 male). Mean age was 40.3 years (\u003cem\u003eSD\u003c/em\u003e = 13.5; range 22 to 74 years). Approximately 67% of patients had an ICD-10 F2 diagnosis (schizophrenia spectrum or delusional disorders), and 30% had an F3 diagnosis (affective disorders, mostly bipolar disorder). One patient (3%) was diagnosed with F1 (substance use), one with F4 (PTSD), and one with F6 (borderline personality disorder), one had missing diagnosis data. Concerning frequency of past isolation, patients reported two on average (\u003cem\u003eM\u0026nbsp;\u003c/em\u003e= 2.2, \u003cem\u003eSD\u003c/em\u003e = 2.83, range: 1 to 15), with most patients (80%; \u003cem\u003en\u003c/em\u003e = 24) knowing the isolation rooms due to previous experience at our ward. Since exact dates of the last seclusion experience were often not known, we compared the year of the experiment with the reported year of the most recent seclusion. Four patients had missing data on the most recent seclusion. For most participants (\u003cem\u003en\u003c/em\u003e = 19; 73%), the last isolation experience occurred in the same year or the year prior to study participation. In five cases, 3 to 8 years elapsed, in four cases, the time elapsed exceeded ten years. Despite this variation, all participants confirmed that they remembered the isolation experience and related room clearly, often due to its emotionally impactful nature. Two patients had no school degree (~7%), two the lowest possible one in Germany (~7%), four a medium (~13%), and the majority (\u003cem\u003en\u003c/em\u003e = 14, 57%) the highest attainable German school degree (57%). Five patients had missing data on education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign effects on ratings of restorativeness, stress, liking, and overwhelm\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFurther statistical details can be found in the Supplementary Materials B Excel file (B_Supplementary_Materials_descriptives_post_hocs_room_designs.xlsx). The between-subjects effect of furniture form (angular vs. curved) was not significant for any variable, with restorativeness (F(1, 28) = .047, p = .829, \u0026eta;\u0026sup2;partial = .002), stress (F(1, 28) = 1.451, p = .239, \u0026eta;\u0026sup2;partial = .049), liking (F(1, 28) = 0.035, p = .853, \u0026eta;\u0026sup2;partial = .001), and overwhelm (F(1, 27) = 0.382, p = .542, \u0026eta;\u0026sup2;partial = .014) all showing no significant differences based on furniture shape. However, means and SDs were in the expected direction, with higher ratings for curved furniture design rooms concerning restorativeness and liking, and higher ratings for angular design concerning stress and overwhelm (restorativeness: Mean\u003csub\u003eangular\u003c/sub\u003e = 3.52, SD\u003csub\u003eangular\u003c/sub\u003e = 1.93, Mean\u003csub\u003ecurved\u003c/sub\u003e = 3.70, SD\u003csub\u003ecurved\u003c/sub\u003e = 1.97; Liking: Mean\u003csub\u003eangular\u003c/sub\u003e = 3.37, SD\u003csub\u003eangular\u003c/sub\u003e = 1.97, Mean\u003csub\u003ecurved\u003c/sub\u003e = 3.65, SD\u003csub\u003ecurved\u003c/sub\u003e = 1.93; \u0026nbsp;Stress: Mean\u003csub\u003eangular\u003c/sub\u003e = 2.30, SD\u003csub\u003eangular\u003c/sub\u003e = 2.00, Mean\u003csub\u003ecurved\u003c/sub\u003e = 2.15, SD\u003csub\u003ecurved\u003c/sub\u003e = 2.10; Overwhelm: Mean\u003csub\u003eangular\u003c/sub\u003e = 2.33, SD\u003csub\u003eangular\u003c/sub\u003e = 2.11, Mean\u003csub\u003ecurved\u003c/sub\u003e = 2.18, SD\u003csub\u003ecurved\u003c/sub\u003e = 2.22).\u003c/p\u003e\n\u003cp\u003eA strong main effect of room design was found for all four dependent variables. Wall design significantly influenced ratings of restorativeness (Wilks\u0026apos; Lambda = .272, F(9, 20) = 5.961, p \u0026lt; .001, \u0026eta;\u0026sup2;partial = .728), stress (Wilks\u0026apos; Lambda = .236, F(9, 20) = 7.201, p \u0026lt; .001, \u0026eta;\u0026sup2;partial = .764), liking (Wilks\u0026apos; Lambda = .103, F(9, 20) = 19.296, p \u0026lt; .001, \u0026eta;\u0026sup2;partial = .897), and overwhelm (Wilks\u0026apos; Lambda = .412, F(9, 19) = 3.009, p = .021, \u0026eta;\u0026sup2;partial = .588).\u003c/p\u003e\n\u003cp\u003eInteraction effects between Wall design and furniture form did not reach statistical significance for any of the variables\u0026mdash;restorativeness (Wilks\u0026apos; Lambda = .855, F(9, 20) = .378, p = .932, \u0026eta;\u0026sup2;partial = .145), stress (Wilks\u0026apos; Lambda = .727, F(9, 20) = .834, p = .594, \u0026eta;\u0026sup2;partial = .273), liking (Wilks\u0026apos; Lambda = .674, F(9, 20) = 1.075, p = .422, \u0026eta;\u0026sup2;partial = .326), and overwhelm (Wilks\u0026apos; Lambda = .705, F(9, 19) = 0.884, p = .556, \u0026eta;\u0026sup2;partial = .295).\u003c/p\u003e\n\u003cp\u003eOverall, these findings indicate that wall design had a strong significant effect on patients\u0026apos; ratings of restorativeness, stress, liking, and overwhelm, whereas furniture form did not significantly influence evaluations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFavored Room Design by Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe post-hoc Wilcoxon signed-rank tests revealed significant differences between specific room / wall designs across all rating dimensions (for details, see Appendix I). Figure 3 depicts mean ratings, SDs, and significant differences found across rating dimensions and room designs. Additional details can be found in the Supplementary Materials B excel file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRestorativeness.\u0026nbsp;\u003c/strong\u003eAll designed rooms were rated significantly more restorative than the control room (all \u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; .02\u003c/em\u003e). Among the designed rooms, Room 9 (beige walls) was rated as significantly less restorative compared to Room 8 (blue wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .014\u003c/em\u003e) and Room 7 (green wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .029\u003c/em\u003e). Additionally, Room 5 (river running through wilderness) was perceived as significantly less restorative than Room 4 (dunes \u0026amp; Baltic Sea) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .046\u003c/em\u003e) and Room 8 (blue wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; .05\u003c/em\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStress.\u0026nbsp;\u003c/strong\u003eAll designed rooms were rated as significantly less stressful than the control room (\u003cem\u003eall p\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; .04\u003c/em\u003e). Among the designed rooms, Room 9 (beige/grey walls) was perceived as significantly more stressful than Room 8 (blue wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .032\u003c/em\u003e). Additionally, Room 5 (river running through wilderness) was rated as significantly more stressful than both Room 4 (dunes \u0026amp; Baltic Sea) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .013\u003c/em\u003e) and Room 8 (blue wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .036\u003c/em\u003e), closely resembling the findings for restorativeness ratings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLiking.\u003c/strong\u003e All designed rooms were rated as significantly more liked than the control room (\u003cem\u003eall p\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; .01\u003c/em\u003e). Among the designed rooms, Room 9 (beige/grey walls) was liked significantly less than Room 8 (blue wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .007\u003c/em\u003e), Room 4 (dunes \u0026amp; Baltic Sea) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .039\u003c/em\u003e), and Room 7 (green wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .036\u003c/em\u003e). Additionally, Room 5 (river running through wilderness) was liked significantly less than Room 4 (dunes \u0026amp; Baltic Sea) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .039\u003c/em\u003e) and Room 1 (pine tree forest wallpaper) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .038\u003c/em\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverwhelm.\u003c/strong\u003e The control room (C0) was perceived as significantly more disturbing than Room 8 (blue wall) (\u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e = .019\u003c/em\u003e) and Room 7 (green wall) (\u003cem\u003ep_adj = .031\u003c/em\u003e) but did not differ from any other designed rooms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCard Sorting (Overall Ranking).\u003c/strong\u003e The ranking task revealed that all designed rooms were preferred significantly more often than the control room (all \u003cem\u003ep\u003csub\u003eFDR\u003c/sub\u003e\u003c/em\u003e \u0026lt; .01). Among the designed rooms, Room 8 (blue wall), Room 7 (green wall), and Room 4 (dunes \u0026amp; Baltic Sea) were most consistently ranked higher than the control and also outperformed other designs. Specifically, Room 9 (beige wall) was ranked significantly lower than Rooms 7 and 8 (both pFDR \u0026lt; .002), as well as Room 4 (pFDR = .0015) (for details, see Supplementary Materials B excel file).\u003c/p\u003e\n\u003cp\u003eThe findings suggest that room design strongly influenced perceptions of restorativeness, stress, liking, and overwhelm, whereas the control room consistently performed the worst across all dimensions, except for overwhelm. To summarize, the Dunes \u0026amp; Baltic Sea nature motive (Room 4), blue (Room 8) and green walls (Room 7) were consistently rated as the most restorative, least stressful, and most liked \u0026ndash; even compared to the beige wall furnished room condition (Room 10). Additionally, blue and green walls were perceived as least overwhelming.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative data analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe content analysis of participant responses (\u003cem\u003eN\u003c/em\u003e = 30) revealed eight key thematic categories, with 17 subcategories related to experiences and needs regarding crisis rooms in mental healthcare settings. These categories emerged through systematic coding and analysis of participant statements\u0026nbsp;and are reported with frequency counts (n) and an anchor example of a participant reference (\u003cem\u003eIDs\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContact and Communication.\u003c/strong\u003e The category contact and communication (\u003cem\u003en\u003c/em\u003e = 26), comprises three distinct subcategories. Codes in the first subcategory \u0026ldquo;general contact\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 12) express the need for regular contact, human interaction, and the need for visitor access\u003cem\u003e\u0026nbsp;(keep contact with the outside world ID2, Allow for family contact ID26)\u003c/em\u003e. The subcategory \u0026ldquo;staff contact\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 6) has specific recommendations for accessibility to staff, highlighting the crucial role of consistent staff presence, particularly during critical situations like physical restraint (\u003cem\u003estaff needs to be there, especially during fixation ID 10\u003c/em\u003e). \u0026ldquo;Contact accessibility\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 7) emerged as the third subcategory, stressing the need for a reliable response system and naming practical solutions for a quick access to staff, like call intercoms \u003cem\u003e(staff should be there or quick to call e.g. call button ID 06)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTherapeutic approach.\u0026nbsp;\u003c/strong\u003eThe category therapeutic approach (\u003cem\u003en\u003c/em\u003e = 28) includes three subcategories. \u0026ldquo;Handling and understanding needs\u0026rdquo; (n=8) refers to transparency about the situation, therapeutic support, and debriefing afterwards. Staff should be calm and qualified to handle acute situations and have knowledge of the patients\u0026rsquo; individual needs and conditions. Participants suggested tools like mood cards to express emotional states. The need for respectful treatment and avoiding perceptions of inferiority was expressed (\u003cem\u003enot to be seen as dumb or less worth, be treated on eye-level ID 25).\u003c/em\u003e Codes in the second subcategory \u0026ldquo;restrictive and coercive measures\u0026rdquo; (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 14) express concerns about the use of coercive measures \u003cem\u003e(use of physical restraint shouldn\u0026rsquo;t be as it is, it should be an exception ID 07).\u0026nbsp;\u003c/em\u003eParticipants questioned the philosophy behind restrictive measures, advocating for humane approaches, open-door policies, and alternatives to strong sedation. Numerous participants emphasized that visual reminders of former violence and coercive measures should be avoided, expressing the potential of triggering negative emotions \u003cem\u003e(traces of violence are burdensome and scary, I get even more panic ID 09).\u003c/em\u003e Recommendations were to hide fixation straps, grids and cameras indicating a threatening environment. The last subcategory \u0026ldquo;basic care\u0026rdquo; (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 9) highlights the need for food and drinks during isolation, as well as access to running water, like a tab and a toilet flush.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecreational activity.\u003c/strong\u003e The category \u0026ldquo;recreational activity\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 31) reflects the need for appropriate occupational activities during seclusion, with the three subcategories \u0026ldquo;recreational opportunities\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 9), \u0026ldquo;access to technical devices\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 12), and \u0026ldquo;physical activity\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 10). In the first subcategory, participants emphasized the overall importance of safe recreational options like books, arts supplies or fixed installations. In the second subcategory, specific suggestions included physical exercise equipment, meditation applications, yoga possibilities, and wall-mounted punching bags (\u003cem\u003eID30\u003c/em\u003e). Technical solutions to listen to music, podcasts or radio, as well as access to mobile phones and a TV were mentioned by several participants in the last subcategory \u003cem\u003e(radio, human voices ID 11).\u003c/em\u003e The data indicated a clear preference for activities that could serve both recreational and therapeutic purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOrientation.\u0026nbsp;\u003c/strong\u003eThe category orientation (\u003cem\u003en\u003c/em\u003e = 12) related to temporal and situational orientation. Participants emphasized the need for basic temporal awareness and spatial orientation through clocks and access to windows with a view to the outside. Participants expressed their need for transparent, early and clear information about their situation, including written documentation about their diagnosis, treatment status, and scheduled staff visits, as well as names and pictures of the staff, specifically the responsible physician \u003cem\u003e(\u003c/em\u003e\u003cem\u003eOpenness of information: Explain the patient what is currently happening and under what conditions they can leave again, as well as the truth about their situation ID 27).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoom design.\u0026nbsp;\u003c/strong\u003eThe subcategory \u0026ldquo;room design\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 17) includes codes that subsume the need for a simple, calm and soothing environment, soft features and not too many stimuli, but with assemblance to a \u0026lsquo;normal room\u0026rsquo;. Provision of calming auditory stimuli (e.g., nature sounds, soothing music) and the incorporation of aromatherapy or scented elements, besides fresh air were recommended. A sufficient room size, to not to feel constricted and have enough space for physical activity, was mentioned as crucial. The subcategory \u0026ldquo;doors and windows\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 14) highlights the wish for the possibility to view outside and fresh air and ventilation, besides being able to open the window themselves. Furthermore, the wish for an open door was expressed by several participants. The most frequent subcategory \u0026ldquo;light\u0026rdquo; (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 13) emphasizes the importance of adjustable lighting and jalousies, preferencing a warm and decent light that can be turned off (\u003cem\u003eLights must not be on all night - it is best to decide for yourself ID 08)\u003c/em\u003e.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe subcategory \u0026ldquo;wall design\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 28) indicates preferences for coloring and wall visuals. Warm and soft colors, particularly blue and green, are frequently mentioned, and wall visuals compared to blank walls are commonly preferred. Participants mention nature motifs, especially those featuring the ocean, water, or dunes and to avoid overwhelming details or overly intricate visuals. Some patients express the preference for not covering the entire wall \u003cem\u003e(Maybe only partially painted, allowing patients to choose where to rest their gaze ID 06)\u003c/em\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eIn the subcategory \u0026ldquo;furnishing and d\u0026eacute;cor\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 33), codes indicate a preference for a furnished room with d\u0026eacute;cor features specifying covers, cushions, carpets, and real plants. Most mentioned is the need for a comfortable bed with bedclothes and cover and an opportunity to sit, like chairs and sofa, with some also naming a table and a closet \u003cem\u003e(bed and clean sheets; without a bed there is no real possibility to rest [in the current condition] ID 27\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHygiene.\u0026nbsp;\u003c/strong\u003eThe last category hygiene consists of the subcategories \u0026ldquo;hygiene standards\u0026rdquo; (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 9) and \u0026ldquo;sanitary arrangements\u0026rdquo; (\u003cem\u003en\u003c/em\u003e = 10). Codes include references to poor existing hygiene standards and highlight the importance of a clean and hygienic environment in seclusion rooms. Multiple recommendations to regularly clean the room, including the use of disinfection and the availability of personal sanitary products like toothbrush and paste, soap, and toilet paper are made. Codes express the need for usable sanitary facilities with a door, containing several mentions of a flushable toilet and a comfortable, non-steel, toilet seat \u003cem\u003e(Cleanliness is super important! ID14)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings contribute to the broader research on psychiatric ward design by demonstrating that wall design may influence patients\u0026rsquo; perceptions of restorativeness, stress, liking, and overwhelm. Specifically, nature-themed designs, especially blue and green colors, as well as a water-themed visual (Dunes \u0026amp; Baltic Sea) were consistently rated as more restorative and likable, while stress and overwhelm ratings were highest for the control condition (empty room with blank walls). Importantly, this study was not only about evaluating specific designs but also about co-developing multi-method approaches for shared decision-making with patients with lived experiences of confinement or seclusion. By engaging patient boards and individuals with lived experience in the process through structured ratings and open questions, we implemented a feasible approach to collaboratively and systematically assess preferences and needs. This participatory approach allowed us to identify design preferences directly linked to subjective well-being during mental health crises. It also underscores a critical gap in current architectural and clinical design practices, where patients are rarely consulted despite being primarily influenced by related choices. Our findings align with existing guidelines and evidence supporting biophilic (ward) design principles (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) and extend this work by identifying water-associated imagery and cool natural colors low in saturation as particularly well-received. On the other hand, our data provide no evidence that furniture form\u0026mdash;curved vs. angular\u0026mdash;affects patients\u0026rsquo; emotional or cognitive responses in a statistically significant way, even though prior research had suggested such effects (e.g., 34,35). This discrepancy may stem from the limited salience of form manipulation in our projected settings, and/ or lack of power due to low sample size.\u003c/p\u003e\u003cp\u003eMoreover, the qualitative responses highlight that participants not only evaluated aesthetics but also reflected deeply on their experience of isolation. Comments reiterate that patients desire spaces and related social interactions that offer comfort, autonomy, and a sense of control\u0026mdash;needs that are rarely met in conventional psychiatric isolation rooms. Patients repeatedly emphasized the importance of light, fresh air, cleanliness, and the ability to orient themselves in time and space. Several participants expressed that a well-designed room might have helped them regulate their emotions better. The demands for better ventilation and adapted lighting and temperature conditions are underpinned by Bramesfeld et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) guidelines from Germany. Several participants wished that the doors should not be locked, as reported in previous studies (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) Furthermore, no signs of coercive practice and violence should be visible in the isolation rooms. A recent study showed that perceived coercion is linked to higher PTSD and lower treatment satisfaction and that combined coercive measures negatively impact functionality improvement and increase re-admission risk (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)). Cameras in isolation rooms were criticized by several participants. In discussion with our co-author and peer support specialist MF, it became clear that the issue is not surveillance per se, but a lack of social reciprocity: to feel seen without having the opportunity to \u003cem\u003esee back\u003c/em\u003e\u0026mdash;to engage, orient, or connect. This asymmetry can intensify feelings of objectification, powerlessness, and isolation. Constant personal observation is rather mandatory, at least during restraint (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), which aligns with participants\u0026rsquo; wishes of constant staff contact and would obsolete video observation. Bramesfeld et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) also emphasize the desire for autonomy, similarly reflected in this sample. Our results show a strong wish for self-directed activity, social contact initiation, and opportunities for selfcare, as well as being able to regulate the room conditions accordingly (e.g. light, windows, doors, water, hygiene). Overall, these findings suggest a complex interplay of needs during coercive measures, emphasizing the importance of maintaining human dignity through appropriate contact, environmental conditions, and meaningful activity options. The results indicate that while safety remains paramount, the implementation of coercive measures as last resort should consider these various aspects to potentially reduce negative experiences and support recovery.\u003c/p\u003e\u003cp\u003eThis insight dovetails with broader debates on the ethics and efficacy of coercion in psychiatry. Isolation, while sometimes deemed necessary, is experienced by many as traumatizing and disempowering (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Architectural decisions that mitigate this experience should therefore not be viewed as \"soft\" design aspects but as integral to a rights-based and recovery-oriented approach to care. Our study shows that patients are not only willing but are also able to contribute meaningfully to such re-design efforts when given the opportunity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite its promising findings, this study has several limitations. The sample size was small (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30) and skewed toward individuals with higher levels of education. The timing of the last isolation experiences varied considerably, albeit most participants had undergone coercion within the last one to two years, reporting vivid memories in general. Additionally, the visual stimuli focused solely on wall design and furniture, whilst other relevant spatial features such as lighting, brightness, sound, temperature, or other spatial design aspects were omitted. This reductionist approach was necessary to ensure cognitive accessibility and feasibility for our patient population but may limit ecological validity, which could be achieved by implementing (multimodal) Virtual Reality (VR) paradigms. Furthermore, in addition to subjective ratings, it would be recommendable to assess objective responses to the designs, such as via physiological arousal (electrodermal activity, heart rate, etc.). Concerning the qualitative study part, it can be criticized that no in-depth interviews were conducted, and verbatim content was not recorded (e.g., using audio equipment), while relying on notes (albeit those were validated and confirmed by participants). This approach was adopted to assure an acceptable time frame for the study including both quantitative and qualitative aspects (1-1.5 hours) and minimize participant burden. Current levels of patient distress or symptom severity were not systematically assessed. While experimenters perceived participants as sufficiently reliable, formal clinical assessments could strengthen future studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis mixed-methods study illustrates the potential of intentional visual design in psychiatric crisis rooms. Nature-inspired wall visuals\u0026mdash;particularly those depicting a soothing ocean scene or calming cool (blue, green) colors\u0026mdash;were associated with increased perceived restorativeness and reduced stress. Perhaps more importantly, the study demonstrates that patients with lived experience of seclusion are not only able to articulate nuanced preferences but should be actively involved in shaping healthcare environments they encounter during their most vulnerable moments. Future efforts to reduce coercion in psychiatry must extend beyond clinical protocols to include architectural and sensory dimensions\u0026mdash;and above all, they must include those most affected at every step.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Medical Chamber Hamburg (vote ID: LPEK-0560, approval date: 20 November 2022). All procedures were conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors agreed to the submission and publication of this manuscript. Data is available from the first author upon reasonable request. We have no competing or conflicting interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded via a grant received by L. Ascone, provided by the Peter Beate Heller-Stiftung (project/ funding ID: T0160/40700/2022/kln).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data and materials are available from the first author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eL. Ascone: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, writing – original draft, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eC. Mahlke: conceptualization, data curation, formal analysis, methodology, writing – original draft, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eN. Tawil: conceptualization, methodology, writing – original draft, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eL. Samaan: conceptualization, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eM. Frisch: conceptualization, investigation, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eL. Nugent: conceptualization, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eR. Nixdorf: conceptualization, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eF. Börncke: conceptualization, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eD. Lüdecke: conceptualization, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eN. Bach: conceptualization, investigation, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eC. Hackbarth: conceptualization, methodology, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eT. McCall: conceptualization, methodology, writing – original draft, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eJ. Gallinat: conceptualization, methodology, writing – review \u0026amp; editing, supervision\u003c/p\u003e\n\u003cp\u003eS. Kühn: conceptualization, funding acquisition, methodology, writing – review \u0026amp; editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGesler WM. Therapeutic landscapes: Medical issues in light of the new cultural geography. Social Sci Med 1 April. 1992;34(7):735\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBratman GN, Anderson CB, Berman MG, Cochran B, de Vries S, Flanders J. u. a. Nature and mental health: An ecosystem service perspective. Sci Adv 1 Juli. 2019;5(7):eaax0903.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHartig T, Mitchell R, De Vries S, Frumkin H. Nature and Health. 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Front Public Health. 2014;2:141.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"acute psychiatry, coercion, architecture, participation, design, biophilia, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-7076311/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7076311/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The design of psychiatric environments influences patient experience, especially in acute crisis settings where perception is altered and emotional vulnerability is heightened. This also applies to crisis rooms, which are often used for seclusion—a practice increasingly criticized for its psychological impact. While guidelines call for de-escalating designs, the perspectives of patients with lived experience of seclusion have rarely informed such efforts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u0026nbsp;\u003c/strong\u003eThis mixed-methods study explored how individuals with lived experience of psychiatric seclusion (\u003cem\u003eN\u003c/em\u003e=30) perceive different visual design elements in simulated crisis room settings. Participants viewed nine digitally rendered room scenarios that varied by wall design (various nature-themed images and cool, pale colors) and furniture form (curved vs. angular) vs. an empty white control room (psychiatric paradigm of no stimulation). They rated each room on perceived restorativeness, stress, liking, and overwhelm and answered qualitative questions about crisis rooms and needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Nature-themed wallpapers—especially an image depicting dunes and water—and blue and green walls, were rated as more restorative and less stressful than both the control and a beige-painted comparison room. Furniture form showed no significant effects. Qualitative responses emphasized the importance of calmness, orientation, positive social interactions, recreational activities, selfcare, and environmental control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Design interventions in psychiatric crisis rooms—particularly those incorporating natural wall imagery and color— improve both the aesthetic and, more importantly, the emotional experiences of patients. The study underscores the feasibility and value of participatory approaches in healthcare design, guiding the decisions needed to co-create spaces that promote better mental health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e The study and main analyses were pre-registered 2024/08/22 at aspredicted.org (#187275) https://aspredicted.org/9ht9-ckwn.pdf\u003c/p\u003e","manuscriptTitle":"Designing Relief: A Mixed-Methods Experiment to Inform Crisis Room Design and Intervention in Acute Psychiatric Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 10:34:05","doi":"10.21203/rs.3.rs-7076311/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-01T08:34:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T20:46:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T16:40:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255191317422133276480160623865253585002","date":"2025-08-06T16:11:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290140533884703027698823218754638801970","date":"2025-08-06T09:08:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-27T12:35:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-27T12:17:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-18T09:18:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-16T19:11:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-07-16T19:08:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf719547-fc37-45d9-8b5b-e77124b649c0","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T17:05:06+00:00","versionOfRecord":{"articleIdentity":"rs-7076311","link":"https://doi.org/10.1186/s12888-026-07780-0","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2026-01-16 16:29:51","publishedOnDateReadable":"January 16th, 2026"},"versionCreatedAt":"2025-08-01 10:34:05","video":"","vorDoi":"10.1186/s12888-026-07780-0","vorDoiUrl":"https://doi.org/10.1186/s12888-026-07780-0","workflowStages":[]},"version":"v1","identity":"rs-7076311","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7076311","identity":"rs-7076311","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}