Without Space We Cannot Heal: Design Insights into Addiction
By Hannah Leyland
Healing and recovering from addiction is a complicated journey, which I came to understand, and am still understanding, as someone who has been profoundly impacted by addiction in my immediate family. Over the years, I have become familiar with the limited spaces that people struggling with addiction can engage with for care: detox facilities, rehabs, emergency rooms, support meetings, group homes, supportive housing, outpatient programs. Often these spaces have major financial, social, and psychological barriers to entry. In my family’s experience, it is often difficult to remember that, like everyone else, a person with substance abuse issues has interests, opinions, knowledge, and an identity beyond being a person who uses drugs, even if it is the addiction that consumes most of our interactions with them.
Acknowledging and unpacking these personal biases and stigmas are essential for designers, because the design of these spaces should be thoughtful and communicate an underlying sense of care, sending a message not only to those who use drugs but also to the public at large that all people are worthy of life, including those who struggle with addictions. Architecture’s response to Drug Consumption Spaces (DCSs), or lack thereof, reflects an absence of compassion or understanding towards the experience of addiction. Designers are not educated to empathize with this experience, let alone how to think spatially about supporting public health efforts to treat and understand its complexities. When society recognizes these facilities as valued, dignified spaces deserving of respect, and when these spaces become a normalized part of healthcare, we can make essential systemic changes and dismantle the dangerous stigmas of addiction and related mental health issues.
Although my family member has never consumed the types of drugs that bring visitors to a supervised injection site, witnessing his exclusion from spaces and places based on his condition, combined with the ongoing global overdose crisis, particularly in my hometown of Vancouver, directed my interests to explore spaces for healing in my 2017 Master of Architecture thesis on Drug Consumption Spaces. In conversations with the architecture chair at my university, I had to argue that the topic was worthy of an entire thesis and involved more than what he saw as essentially a furniture selection project. I found an invested professor, and began my research by visiting Vancouver’s Downtown Eastside weekly for four months. After graduation, I continued this research by collaborating with a researcher through the BC Centre for Disease Control and worked collectively on a grant-funded project designing a supervised inhalation room prototype in conjunction with an architect, Sean McEwen, a pain and addiction medicine physician, Dr. Marcus Lem, and Russ Maynard of the Portland Hotel Society. Involvement in these projects allowed me to engage with a spectrum of individuals: not only with those who have lived experience of drug use, but also community members, healthcare providers, social workers, and professionals involved in this multifaceted reality. In my experience, it is critical for architects to listen to and learn from these marginalized voices, in order to best create spaces for healing and recovery.
DCSs are different from typical healthcare settings in that they are not intended to “cure” addiction, but rather to reduce harm by supporting individuals along their often unique and non-linear journeys from illness to wellness. The aim is to reduce substance-related issues without emphasizing sobriety or reduction in use. Usually, under clinical supervision by nurses, these centres offer access to healthcare, counselling, referrals to social services, and treatment options like detoxing and methadone. These specialized facilities offer a safe alternative to the typically high-risk environments drug users are forced into by the nature of their addictions. Since drug use is criminalized, trade and consumption usually takes place in hidden, unhygienic, and often dark public spaces, such as parks and alleyways, with the constant threat of law enforcement looming in the background. People with addictions who are fortunate enough to have the privacy of a home often engage in solitary drug use where there is a higher risk of overdose emergencies without access to help. In a supervised environment, lethal risks like consuming a drug tainted with Fentanyl, consuming too quickly, sharing needles, spreading blood-borne diseases, or simply not being able to make a life-saving phone call can be prevented.
Geared to support neglected and excluded populations, address health inequities, and resolve public health and safety tensions related to public drug use, (1) DCSs effectively reduce the spread of infectious diseases, overdose deaths, and improperly discarded injection equipment. These spaces have broader peripheral effects in the public realm and are proven to encourage an improvement of order, health service and drug treatment accessibility, and taxpayer savings. (2) For the individual, they provide a starting point for healing and support upward social mobility, which benefits the community as a whole. Considering the reality that people will consume drugs regardless of their legality, providing a clean and safe place for use is a logical step towards better public health. If people are given a welcoming space along with access to basic human rights such as bathrooms and potable water, communities could be more resilient.
According to the International Network of Drug Consumption Rooms, there are approximately 150 facilities operating globally at different scales in eleven countries. (3) Vancouver remains at the forefront of harm reduction research and efforts, as the Downtown Eastside neighbourhood, sometimes referred to as “Canada’s poorest postal code,” is arguably the epicentre of drug use in Canada, if not North America. Although Vancouver is frequently rated one of the most liveable cities in the world, in its shadows is a neighbourhood infamous for extreme poverty, homelessness, addiction, and other mental and physical illnesses. In addition, the gentrification of the area is dangerously pushing inhabitants further into the shadows with no platform for self-advocacy.
Image 1/ Injection Room, Insite, Vancouver, Canada, 2017. Photograph by Hannah Leyland
In 2003, North America’s first legal supervised injection site, Insite, opened in the Downtown Eastside. Providing a space with hygienic equipment and professional supervision, Insite has facilitated more than 3.6 million safe injections, and its success has been widely documented in research areas of public health, safety, economics, and personal wellbeing. (4) While overdoses have occurred at Insite, with 6,440 reported to date, there have been zero fatalities due to immediate intervention by on-site medical staff—a stark contrast to the province’s over five thousand overdose deaths in the last four years alone. (5)
The way designers understand, respond to, value, and talk about a space and its intended occupants can impact healing. Permitting the illicit, intimate, and extremely stigmatized activity of drug use in a space challenges learned notions of public/private, illegal/legal, regulated/spontaneous, safe/risky, and surveillance/autonomy. Understanding the architecture of Insite highlights these unique challenges. Its architect, Sean McEwen, has involved his practice in numerous socially minded projects throughout the Downtown Eastside, often looking for ways to involve the intended occupants in the design process. With input from members of Insite’s operating organization, Portland Hotel Society, including Liz Evans, Dr. Dan Small, and Mark Townsend, McEwen considered humanistic components in his design: respect for the occupant, an interior that is welcoming and “not like a morgue,” avoiding clinical colours and lighting, and making the space comfortable, not oppressive, for staff.6 McEwen insisted on personally paying for lighting that the health authority deemed “too nice for a space for addicts.” (7)
Insite is located in a renovated building on Hastings Street that previously housed a longstanding sandwich shop. (8) It’s intentionally discreet, blending in with the street, normalizing its existence within the neighbourhood. It’s easy to miss if you’re not looking for it. The facility is designed with a horseshoe layout, with two doors that front Hastings Street. Individuals enter through one door and complete the u-shaped chronological sequence—pre-injection, injection, and post-injection—and exit through a separate door. The entire space is wheelchair accessible as many members of this population have mobility issues. This one-way circulation strategy maintains order in what could become a conflicted or chaotic environment.
Insite is intended to create a doorway into healthcare, especially for people within this community who have negative experiences with institutional settings like hospitals or prisons. Insite is not solely an injection site. Visitors may seek to talk to a nurse or peer worker, inquire about detox or other services, or simply meet their friends. Many people in this population do not have cellphones; instead, they use a message board to leave notes such as “J, had to run, see you here tomorrow 2pm, take care man.” In traditional hospitals and clinics, this group faces many physical, social, and emotional barriers, which Insite tackles by offering a human-centred approach. Security is maintained with cameras rather than a guard, which could otherwise be a source of intimidation and create an un-trusting atmosphere. The intake desk is welcoming with no forms to fill out, drawing focus towards trusting human interactions. The visitors of the space are called “participants,” implying agency and equality within the facility, and are considered integral contributors to its success and function. The simple ability to have legal access to a space and stake presence within it, even for a limited amount of time, holds so much value to people who have next to nothing.
Participants enter from the street and first-time visitors are asked to choose a code name as a way to maintain anonymity which, once selected, can be changed at any time. If a participant is unwilling to provide certain information, they are not pressured to do so as the main objective is “getting people into a lifesaving service.” (9) Often participants have to wait, as there are only twelve booths but seven hundred to 1,300 visitors daily. Participants can be seen waiting in the rain along the unsheltered sidewalk on Hastings Street, in an agony few of us will ever understand. Not visible from the waiting area, the injection room is slightly warmer in temperature than other areas in the building to help participants feel more physically relaxed and locate their veins more easily. Resembling voting booths, a row of stainless-steel partitions along the wall sit opposite the nurse’s station, each outfitted with a mounted sharps bin and a mirror to help the participants with the injection. The atmosphere is purposefully not clinical: the black-painted, exposed ceilings are over ten feet high, dotted with track and pendant lighting, and a mix of classic rock plays in the background. (10) The participants select equipment such as tourniquets, needles, spoons, or alcohol wipes from the nurse’s station counter and proceed to the sturdy, rounded, plastic armchairs at one of the numbered booths. Nurses are not permitted to physically assist with injections, but can verbally assist. McEwen describes how the partitions were a requirement of Health Canada, intended to prevent the exchange of drugs within the space.11 The participants face a mirror with their backs to the nurse’s station. These mirrors are for supervision and are intended to help the participants feel more secure, allowing them see their surroundings while injecting. I witnessed participants using the injection booth mirrors to apply makeup, explaining to me that this is the only mirror they can access all day.
The post-injection room, referred to as the “chill-out room,” is run by a peer-worker. Participants can rest, have a beverage, and engage in conversations with friends, staff, or peer-workers if desired. The space is sparse with a fixed stainless-steel table and chairs along the periphery. The health authority insisted that McEwen not design anything “too comfortable.”12 Visits to the chill-out room often involve chats about a recent hockey game, seeing photos of participants’ children, or chats about the weather, the same conversations the rest of the world is having. Similarly, during the community meetings for the Supervised Inhalation Room Prototype project, it was clear that people within this community came from a variety of cultural, educational, and socioeconomic backgrounds and for one reason or another ended up in the Downtown Eastside. One member who was an engineer by training asked about wood-frame construction, another from a medical background voiced her concern about injecting in a place with second-hand smoke, some wanted to ensure there would be a bathroom, a few offered ideas on colours and artwork, others were worried about where their dog would be tied up or where their bike could be stored. This wisdom gleaned from the people who will be using the space determined design decisions that are ultimately vital to its success and longevity of the space.
Design involves understanding the needs of a client and stakeholders, and using this understanding to determine spatial parameters. In the case of Insite, these needs are those of participants (the user group), staff, the health authority, and the public. Since the participants of Insite are predominantly homeless, anything from suitcases, shopping carts, bikes, or even dogs are welcome and accommodated without hesitation. At the same time, the space must feel comfortable and safe for staff. Active input from the client group is essential to the success and longevity of the space. Although there is no in-person security, there is a security system and a safe room should threatening behaviour occur. The government and health authority have an interest in safety, protection, sanitation, budget, occupational health, and safety standards for staff. The public wants to ensure that the space is only accessed by those who need it and that it does not have negative impacts to their community. Architects and designers have the role of balancing the goals and expectations of all stakeholders and translating those needs into a representative design strategy.
Through my family’s experience, I came to realize that what recovery looks like varies from person to person. For some the goal may be sobriety, but for many it’s personal growth, talking about past trauma, mending relationships, finding meaningful activities, seeking spiritual nourishment, reducing physical harm, or simply just getting through another day alive. Providing dedicated space for those struggling with addictions is an act of compassion. It indicates to those affected and their supporting parties that the illness is worthy of acknowledgment and healing. An architect can be a powerful mediator between notions of public wellbeing and the built environment. Wherever possible, I believe that architecture has a primary obligation to create socially sustainable spaces and that the architect must learn to be a listener and facilitator. There are too few people fighting for the wellbeing of individuals like those of Vancouver’s Downtown Eastside community. There are even fewer architecture and design professionals working within or for this community, despite how desperately these marginalized groups need support. The architecture of these spaces provides individuals with the opportunity for healing. We all deserve space, and without space we cannot heal.
Image 2/ Message Board, Biltmore Hotel, Vancouver, Canada, 2017. Photograph by Hannah Leyland
Endnotes
(1) “Supervised Consumption Sites,” Vancouver Coastal Health, accessed November 15, 2020, http://www.vch.ca/public-health/harm-reduction/supervisedconsumption-sites
(2) “Alternatives to Public Injecting” (consultation report, Harm Reduction
Coalition, New York City, 2016), https://harmreduction.org/hrc2/wpcontent/uploads/2020/08/Resource-SupervisedConsumptionServices-AlternativestoPublicInjections.pdf
(3) International Network of Drug Consumption Rooms, accessed November 15, 2020, http://www.drugconsumptionroom-international.org/.
(4) “Insite User Statistics,” Vancouver Coastal Health, accessed November 15, 2020,http://www.vch.ca/public-health/harm-reduction/supervised-consumption-sites/insite-user-statistics.
(5) “Illicit Drug Toxicity Deaths in BC January 1, 2010–September 30, 2020” (coroners’ report, Ministry of Public Safety & Solicitor General, British Columbia, October 20, 2020), https://www2.gov.bc.ca/assets/gov/birth-adoption-deathmarriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf.
(6) Sean McEwen (architect of Insite) in discussion with the author, January 2020.
(7) Ibid.
(8) Larry Campbell, Neil Boyd and Lori Culbert, A Thousand Dreams: Vancouver’s Downtown Eastside and the Fight for Its Future (Vancouver: Greystone Books, 2009).
(9) Darwin Fisher (Coordinator of Insite) in discussion with the author during tour, March 2017.
(10) Ibid.
(11) Sean McEwen (architect of Insite) in discussion with the author, January 2020.
(12) Ibid.
Bio
Hannah Leyland holds a Master of Architecture from the University of British Columbia, a Bachelor of Science (focusing on Quantitative and Population Health) from Simon Fraser University, and a diploma from the Design Discovery Program at Harvard University. Combining her interests in architecture and health, Hannah seeks to utilize design thinking to address the addiction crisis. Hannah is currently registered as an Intern Architect with the Architectural Institute of British Columbia and is pursuing licensure.
