social experiment doctor's waiting room

Course blog for INFO 2040/CS 2850/Econ 2040/SOC 2090

Social Experiment: Information Cascade

http://dailyoftheday.com/social-experiment-of-the-day-social-conformity/

The article and video (in the article) discuss social conformity. The video shows a social experiment that was done. A woman walked into an optometrist’s waiting room. The waiting room was full of other “patients” that were part of the experiment. A little after she sat down, there was a beep in the waiting room and all the patients stood up and sat down. The woman just looked around and after three beeps of this happening, she joined them in standing up and sitting down without knowing why they were doing it or even asking why. This continued for a while, and all the patients were called into the doctor’s office until she was the only one in the waiting room. She continued to stand every time there was a beep even when she was alone. Another patient came in (not part of the experiment/doesn’t know what’s happening) and observed her doing this, asked her why she was doing it which she responded to with “Everyone was doing it…so I thought I was supposed to,” and joined her in standing up and sitting down in the next beep. Soon the waiting room was full of new patients who all were standing up and sitting down after every beep without knowing why.

This is an example of an information cascade. The woman and every person after her inferred that the reason people were standing up every time they heard a beep was more powerful than their own private information so it made sense for them to join in standing up even though their private information gives them no reason to. They left their own information for inferences based on earlier people’s actions. The article argues that this is social conformity, but as what was said in lecture and stated in the textbook, it’s not always easy to tell an information cascade apart from social conformity. I don’t think the patients in the waiting room mindlessly followed the croud–i think they all thought there must be a good reason for everyone to stand up when it beeps so I will too. 

December 4, 2019 | category: Uncategorized

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Brain Game: Tendency to Mimic Behavior Can Lead to Positive Change

After only a few beeps, the subject began standing up with the rest. She was not rewarded or instructed to do so, but she did it anyway. Slowly all the other participants left the waiting room, leaving only the subject. She kept standing at the beep. Then as new subjects entered the waiting area, all but one person mimicked her behavior and stood at each beep.

We humans are funny creatures. We have a natural tendency to go along with the crowd. Perhaps wanting to fit in is a survival mechanism, or maybe it is a social thing. Regardless, the fact is that even without logical reason we will conform to the environment and behaviors around us. We see it in residents demanding clothing protectors, even thought they never used them before. We see residents head back to their rooms after the evening meal and, at the call light, race to go to bed even though they used to enjoy staying up in the evenings. Could this be an anchor that has held long-term care in its institutional mindset?

Doing what everyone else does is a powerful human trait, but maybe we can use this tendency to create positive change. If people are so strongly driven to replicate the behaviors they are exposed to, then let’s give them some positive behaviors to grab ahold. And this goes for staff, families and residents alike. Look at an objective in your daily environment. What behaviors are mimicked by others? Are they positive ones? Are we building people up or tearing them down? The good news I see in the Brain Game experiment is that even when just one person exhibited a behavior, those around joined in. So it only takes one person to get something positive started.

We have the opportunity to use this human trait to make change, to plant seeds for positive behaviors and actions. If those around join in and behave the way we behave, then we can be a catalyst for change. However, we must be very consistent and aware of how others see us. If we are positive and supportive sometimes, and grumpy and talk about others behind their backs at other times, which behavior will others most likely repeat? Try playing some brain games of your own, and present those around you with positive behaviors. At the same time be very conscious of any negative behaviors you may be conforming to and speak up about them.

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What Other People Say May Change What You See

By Sandra Blakeslee

• June 28, 2005

A new study uses advanced brain-scanning technology to cast light on a topic that psychologists have puzzled over for more than half a century: social conformity.

The study was based on a famous series of laboratory experiments from the 1950's by a social psychologist, Dr. Solomon Asch.

In those early studies, the subjects were shown two cards. On the first was a vertical line. On the second were three lines, one of them the same length as that on the first card.

Then the subjects were asked to say which two lines were alike, something that most 5-year-olds could answer correctly.

But Dr. Asch added a twist. Seven other people, in cahoots with the researchers, also examined the lines and gave their answers before the subjects did. And sometimes these confederates intentionally gave the wrong answer.

Dr. Asch was astonished at what happened next. After thinking hard, three out of four subjects agreed with the incorrect answers given by the confederates at least once. And one in four conformed 50 percent of the time.

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Behind a Locked Door

I–The Pale-Yellow House

One night in March, 2021, Evy Mages, a photojournalist in Washington, D.C., opened her laptop and, with trembling fingers, typed into Google the address of a villa in Innsbruck, Austria. For decades, Evy, who was fifty-five, had been haunted by memories of the house, where she had been confined for several months, starting when she was eight. She could still picture its pale-yellow exterior and the curved staircase and dark-wood panelling inside, but she’d kept what happened there a secret—even from a therapist whom she’d credited with saving her life. Evy’s memories of the place had become dreamlike, simultaneously vivid and vaporous.

She remembered being wrested from bed in the middle of the night at the home of her foster family, in the Alpine valley of Kleinwalsertal. She was hustled into a stranger’s car and driven through the mountains to Innsbruck. Nobody told her what kind of place the villa was, or how long she’d stay. Perhaps two dozen children were living there. Adults in white lab coats regularly administered shots and pills, and when it was time to eat the children were required to use weirdly abbreviated language: “bitte, Löffel” (“please, spoon”); “bitte, Gabel” (“please, fork”). In the morning, Evy attended school in the villa. At night, she had to sleep with a blanket pulled tight under her armpits, her arms ramrod straight by her sides, to insure that her hands couldn’t wander. She was terrified of wetting the bed, because whenever she did the white coats would awaken her, even from deep sleep, and march her to the bathroom for an ice-cold shower; she would then have to stand in a corner for the rest of the night. She’d be shivering and it would be dark, except for the murky green light from a fish tank, which she was forbidden to look at.

Children at the villa were issued thick, bloomer-like underpants. Shrill alarm bells rang day and night. Orders blared from loudspeakers that hung over doorways; to Evy, the voices seemed to belong to all-seeing powers. Sometimes she was summoned to recount her dreams to an adult. This unnerved her: she could tell that there was considerable peril in the exercise, though she didn’t understand why. She felt clever when she told her interrogator that she couldn’t recall any dreams, but the result was punishment: she had to sit alone in a room until she came up with something. Once, she was shown a set of farm animals and told to assign to each one the identity of a person in her foster family. Evy agonized—surely it was the wrong choice to make her foster mother the pig.

One day, she and some other children were told to line up in front of a closet to receive a treat. When the person in charge dropped dates into Evy’s skirt, which she had dutifully held out, she saw that ants were crawling on the fruit. Evy shook her skirt frantically, jumping up and down. White-coated adults carried her to the bathroom, where they held her down on the tile floor and administered a shot.

The pervasive sense of shame and surveillance had created a blurring effect. Evy could recall almost nothing about the children who had slept alongside her, in one big room, perhaps because talking to one another was largely banned. A yellow dot had marked her bed and the location of her toothbrush, and the color had perturbed her ever since. As an adult, she reminded herself that yellow was a happy shade, and tried to overcome her aversion by bringing home sunflowers.

When Evy was twenty, she moved to the United States. She settled first in New York City, where she eventually got a job at the Daily News; in 1998, she married a reporter she’d met there, Paul Schwartzman. They relocated to D.C. and had three children, Sammy, Stella, and Lily. She and Schwartzman later divorced, but over the years Evy amassed a tight circle of friends in D.C. and built a close relationship with each of her kids. In middle age, she felt more grounded than she had ever been. It was time to turn the key she’d been carrying around for decades—she’d never forgotten that the villa was on Sonnenstrasse—and enter those rooms again.

Nothing about Evy’s childhood had been easy, so in some ways it puzzled her that the months on Sonnenstrasse loomed so large in her mind. She was born in 1965 in an Austrian town called Feldkirch, to a twenty-two-year-old single mother who was staying in a Catholic home for women. She relinquished Evy to foster care. A family took in Evy when she was three, with an eye to adoption, but the mother, Anni, seemed to quickly turn on her. Anni ran a bed-and-breakfast in the family’s home, a stucco chalet with carved wooden balconies, tucked into a steep mountainside. Her husband, Erich, was a postman, making deliveries on skis in the winter and often retreating to a hut that he’d built, farther up the mountain. Managing the B. and B. put a strain on Anni, who once described herself to a doctor as “nervous.” She soon became convinced that any bit of wear and tear—a scratch on a wall, a chip on a plate, a spot of missing paint on a crucifix—was an act of malice by Evy. As Evy remembers it, Anni would point out the damage, and if Evy didn’t take responsibility for it Anni would hit her until she did. As punishment, Anni would send Evy to the cellar or lock the door to the bathroom so that she couldn’t use it. Anni told Evy that her mother had been a whore.

If Evy didn’t like the treatment she was getting, Anni warned, she could always go to a “worse place.” Although Evy was afraid of Anni, she yearned for her love, and dreaded being sent away. Anni and her husband had a biological daughter, who was a year older than Evy. This girl was well behaved and shy; Evy was tomboyish, exuberant, and a little clumsy—the kind of kid who always had a banged-up shin or a skinned knee. At school, a priest sometimes scolded her, mournfully, for giving her delicate foster mother such a hard time. When Evy was sent to the villa, it confirmed her worst fear: nobody wanted her.

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After a number of months in Innsbruck, Evy was abruptly sent back to Kleinwalsertal. But Anni soon became impatient with her again, and shipped her off to an orphanage in Kempten, Germany, run by nuns. There, Evy forged bonds with her fellow-orphans, who walked to school together in donated clothes and weren’t allowed to participate in after-school activities. (The nuns told Evy that people like her were “gutter trash.”) As a teen-ager, she began looking after the younger orphans—teaching them to tie their shoes, combing lice from their hair—and this came to feel like a sweet responsibility. Growing up, Evy told me, she’d trusted that God would eventually punish the cruel adults in her life. Then, one day, she saw a priest chase away a poor, mentally ill woman who was trying to give him some flowers—and she began to lose her faith.

As an adult, Evy couldn’t bring herself to tell her kids about Sonnenstrasse, but she did talk about the orphanage. When her affectionate and empathetic youngest child, Lily, became a teen-ager, she was fascinated to hear about her mother’s life at that age. The nuns, Evy recalled, sometimes yanked her hair or slapped her. Once, she’d been hit after using a pen as eyeliner—makeup was forbidden.

Evy aged out of the orphanage at sixteen. She attempted a second return to Kleinwalsertal, where she began studying hotel management at a nearby school, but Anni still couldn’t abide her. Evy was on her own. For a while, she worked at another local guesthouse, whose owner let her stay in a room upstairs, then moved to Vienna, where she felt lonely and unmoored. One day during that period, she drove to Innsbruck with an older friend, Jimi, a free spirit who’d run a bar in Kleinwalsertal and had watched out for her there. During the road trip, they sang along to a cassette of “The Threepenny Opera.” When they arrived at Sonnenstrasse, they knocked on the villa’s arched front door. A panel slid open, and a face appeared. Evy tried to ask about her stay there. The panel closed, with a clang.

When Evy scrolled through her search results for the Sonnenstrasse villa, which were in German, she noticed an unusual word: Kinderbeobachtungsstation, or “child-observation station.” She’d always assumed that the villa had been some sort of psychiatric facility. It had seemed like “a transfer hub,” as she recently put it—a place where children were monitored, classified, and then sent to other institutions. From the search results, Evy learned the name of the woman who’d headed the place: Dr. Maria Nowak-Vogl, a psychologist at the University of Innsbruck. Typing Nowak-Vogl’s name into Google, she learned that the villa had indeed been a psychiatric facility, of a very peculiar kind. In 2013, an expert commission under the aegis of the Medical University of Innsbruck had issued a damning report about the facility, saying that Nowak-Vogl had perpetrated systematic abuse under the guise of dealing with “difficult” children. The report came three years after a muckraking Austrian historian named Horst Schreiber published a book that reported on Nowak-Vogl, “ In Namen der Ordnung ” (“In the Name of Order”). Schreiber had interviewed dozens of Nowak-Vogl’s victims and had publicly demanded that the Austrian government offer them apologies and financial compensation. The government, Evy learned, was now doing so.

A news article about the commission’s findings described the villa as a combination of “home, prison, and testing clinic.” The commission had reviewed medical records and reported something shocking: children had been injected with epiphysan, an extract derived from the pineal glands of cattle which veterinarians used to suppress estrus in mares and cows. Nowak-Vogl, a conservative Catholic, had wanted to see if epiphysan would suppress sexual feelings in children, as well as discourage masturbation, thus rendering her charges more “manageable.” Masturbation—among both adolescents and young children, who use it to self-soothe—was a preoccupation of Nowak-Vogl’s. So was bed-wetting. Her staff was instructed to keep charts documenting urination and bowel movements, and to check children’s underwear “with the eyes or the nose.” Schreiber described her as being “on a crusade against masturbation and sexual excitedness.”

The villa’s staff, Evy learned, hadn’t focussed on treating individual children. As Michaela Ralser, a University of Innsbruck professor who worked on the commission’s report, wrote, Nowak-Vogl’s goal was “protecting society from psychologically conspicuous children and adolescents.” Ralser described the villa as “a closed system . . . characterized by the authoritarian leadership style of its unrestricted leader.” As Evy later discovered, there was a pronounced Nazi lineage to the practices of child psychiatry in Austria that shaped Nowak-Vogl’s approach. The story of the Innsbruck child-observation station, and other places like it, was entwined with the history of postwar Austria and its deeply flawed de-Nazification.

Nowak-Vogl had started housing children on Sonnenstrasse in 1954, under the sponsorship of the Tyrolean government, and had overseen the operation until 1987. At least thirty-six hundred children, most of them between the ages of seven and fifteen, had been confined for up to several months at a time. Nowak-Vogl, who had close ties to Austria’s child-welfare system, determined each child’s next placement. Some kids went to orphanages; others, to reformatories, where they often had to work in laundries or otherwise provide free labor. Nowak-Vogl also sent children to work with farming families. Occasionally, a kid got to go home.

Evy felt a rush of validation. All of us have childhood memories that sporadically pop into our minds, like slides in a randomly organized carrousel, and it can be hard to make sense of these fragments. But most of us can check our recollections against those of parents, siblings, cousins, childhood friends. Evy hadn’t been able to speak with anyone about the villa. Now, as she scrolled through articles and reports about it, she confirmed, and clarified, many bewildering aspects of her experience. Staff members, she learned, had been alerted to bed-wetting by alarm-bell sensors lodged in children’s mattresses—and sometimes in their bulky underwear. Evy had correctly recalled the consequence: a freezing shower. The commission report noted that the silence pervading the villa had been easy to maintain in part because the children had frequently been given psychotropic drugs and tranquillizers, often in response to “disciplinary difficulties.” Medical records showed that they had also been dosed with potent sedatives, including Rohypnol. Only a small percentage of the children were given epiphysan. Evy wondered if she’d been one of them.

The commission report also mentioned “bans on speaking” and a “criminalization of feelings” when residents tried to socialize. Schreiber, who contributed to the report, wrote, “Friendships and expressions of affection for other children and young people were frowned upon and prevented, often interpreted as sexualized behavior.”

The report included a document that listed Nowak-Vogl’s house rules from 1979 and 1980. Twelve pages long and printed in a tiny font, it is perverse in its despotic specificity. Personal belongings, including books and dolls, were taken away upon arrival. Children had to clean their plates scrupulously: “Only bones, cartilage, and bay leaves may be placed to the side.” Unfinished food was to be presented at the next meal, and the next, until it was eaten. “Romping, whistling, screaming, and singing” were forbidden. “There is absolute silence when the soup is served,” the document noted. “Even marginal remarks or seemingly justified questions are not allowed to pass.” Staff members were instructed “to make mealtimes as short as possible and not to sit down with the children out of inertia.” The monitoring of toilet habits was described in exhaustive detail, and there was even a rule about how toothpaste should be “sparingly pushed between the bristles” of a child’s brush.

The more that Evy read, the angrier she became. Nearly four thousand children? Until 1987? Eight or so similar facilities had operated in Austria after the Second World War. How many thousands of children had spent time in repressive psychiatric institutions like hers? At all the facilities, confused children were brusquely evaluated for “misbehavior.” But only the Sonnenstrasse villa was so consumed with stamping out sexuality.

In September, 2021, Evy approached me to see if I’d look further into her story. We had been friendly acquaintances for years. Our kids had attended the same elementary school, in Northwest D.C., and I’d occasionally run into her in the neighborhood, or at a demonstration that we were both covering. Evy was high-spirited, flaxen-haired, and casually glamorous, with a wide, dazzling smile. Her accent, full of trilled “r”s and “v”-like “w”s, reminded me of the Velvet Underground’s Nico. In a D.C. milieu crowded with former student-council presidents, she stood out. Sometimes I’d see her in the middle of the day leaning into deep conversation with a friend at the local Starbucks; it was as if she’d transformed the place into a Viennese coffeehouse, the way dropping a colorful scarf over a motel-room lamp can make the drab space look dramatic.

Though we hadn’t had many one-on-one conversations, I’d been struck by Evy’s emotional directness and impetuous generosity. “The outside matches the inside with Evy” is how her friend Keltie Hawkins, a therapist, put it. I’d noticed, too, that Evy genuinely liked and fiercely defended kids. More than almost any parent I knew, she was comfortable around defiant teen-agers. When my daughter was in middle school, with purple-streaked hair and an emotional intensity that discomfited some adults, Evy made a point of telling me how great she was. I learned later that Evy would take in her kids’ friends, and friends of her kids’ friends, when they had conflicts with their own families. Hawkins called Evy’s house “the wayward station.” She recalled seeing Evy cross a playground to tell a man who’d hit his daughter, “How dare you—that’s your child, not your property.” And Evy had once confronted some cops who’d caught friends of her teen-age children shoplifting at a local store. “I’ve known these kids since they were this tall,” she told the officers. “They’re good kids.” The teens got off with a warning. Evy liked to describe herself as “deeply anti-authoritarian,” and the more she told me about her past the more sense that made.

A few days after Evy learned about Nowak-Vogl, she e-mailed one of the commission’s lead researchers, Elisabeth Dietrich-Daum, a professor at the University of Innsbruck. “Never did I imagine there would be a reckoning,” Evy wrote, adding that she was “overwhelmed with gratitude to you and your team for . . . bringing these atrocities to light.” In another e-mail, she wrote, “I am immensely grateful that I somehow had the strength to create a life after growing up in Austria as a freak, a reject, and a test object.” Dietrich-Daum replied to Evy, noting that she could apply for financial compensation from the State of Tyrol’s office for Opferschutz , or victim protection. She could also obtain her medical records.

By the time Evy told me about the Kinderbeobachtungsstation , she’d reached out to other scholars and had submitted testimony to the commission. She was moved when she received a letter of apology from Gabriele Fischer, a Tyrolean official in charge of youth welfare. Fischer said that Evy was entitled to an immediate payout of fifteen hundred euros; upon turning sixty, she could receive a pension of three hundred euros a month. “What happened to you should never have happened,” Fischer wrote. “I can only promise to learn from your story.”

Evy requested a copy of her medical file from the villa. Her stay had lasted from December 27, 1973, to April 17, 1974. (Her foster parents must have thought they’d been kind to wait until after Christmas to ship her off.) The file was chilling, Evy told me, and she’d only begun delving into it. It included a small photograph of her at eight, smiling brightly under ragged blond bangs. One reason she’d been reluctant to revisit her mistreatment at the villa, she explained, was that “having been in a mental institution just comes with a stigma, no matter how unjust it is.” But learning that so many other kids had been abused there had “totally blown the lid off,” and she now wanted to “know everything.” Who was Maria Nowak-Vogl, and how had she exercised unchecked tyranny for so long? What ideas and training had shaped her views of children’s minds and bodies? How had Evy ended up under her power? Had Evy been given epiphysan—and, if so, were there long-term effects? How many victims knew about the restitution program?

We agreed to travel to Austria together. There were people—officials, researchers—whom Evy wanted to meet in person. She was also considering going to the villa. The trip wouldn’t be easy: Evy hadn’t been back to Austria for more than twenty-five years and had not planned to return. The country felt claustrophobic to her—a cold basement crammed with detritus from her past. Although Evy remained fluent in German, she’d pointedly avoided speaking it for decades. In America, she told me, she’d built a new life, which “did not translate into the life or language of my mother tongue.” She’d undergone therapy in English; she’d raised her children in English, picking up phrases of comfort and nurture that her American friends used. Evy was a natural as a mother, but, given the deprivations of her childhood, she had to learn the lingo. (When she heard a friend in D.C. say, “Aw, kiss the boo-boo” after her toddler scraped his knee, Evy added that to her repertoire.) Eschewing her native tongue wasn’t a therapeutic method that anyone had recommended, but she’d found it a balm. I understand some German, but we agreed that, whenever possible in Austria, we’d conduct our inquiries in English. In April, 2022, we met up in Innsbruck, for the first of two trips that we’d make together.

Innsbruck is a pretty university town whose backdrop of snow-cloaked peaks can make a visitor feel dizzy. Many buildings are painted in sugary Habsburg pastels; the Inn River, a tributary of the Danube, rushes through the city center, where students crowd cafés and beer gardens. For Evy—whose every minute in Innsbruck was a Foucauldian nightmare—none of this felt familiar. Neither did the people we were meeting there. They seemed like representatives of a new Austria, unafraid to reckon with the darkest periods in their country’s past.

Ina Friedmann, whom we saw on our first morning, had become one of Evy’s heroes. A historian of medicine at the University of Innsbruck, Friedmann had worked on “ Psychiatrisierte Kindheiten ” (“Psychiatrized Childhoods”), a 2020 book of essays about Nowak-Vogl’s child-observation station. Evy was delighted to discover that Friedmann, who is thirty-eight, looked like an avatar of alternative Austria: her hair was indigo, she wore a metal-studded jacket, and she carried a tote bag emblazoned with the English phrase “ only anarchists are pretty .” Friedmann’s academic writing was careful and restrained, but in person she was warm and expressive. She and Evy hugged for a long time, like old friends.

We sat down for coffee in the courtyard of a café—it was chilly, but Friedmann could smoke cigarettes there—and discussed what Evy had learned about epiphysan. Her chart hadn’t mentioned the drug, but, given all the shots she remembered, she suspected that she’d received it. Her chart noted that she’d been caught in class with “her finger up her nose or her pen in her mouth, and her hand down her pants while she masturbated.” (I told Evy that I had to applaud her ability to multitask self-comfort in such an environment.) Moreover, Evy was a bed-wetter and a child born out of wedlock—categories that Nowak-Vogl associated with deviance. Friedmann said it was certainly possible that Evy had received epiphysan. Nowak-Vogl had been administering the extract since at least the early fifties; in a 1957 paper on “hypersexuality,” she’d written about giving epiphysan to an unspecified number of children. Epiphysan had been tested on humans once before: in the nineteen-thirties, male prisoners in Vienna were given the drug, which appeared to temporarily curb the impulse to masturbate. But Nowak-Vogl was the first to administer it to children. She said that it suppressed “physical and mental restlessness.” In 2015, Friedmann had reviewed some fourteen hundred medical records, identifying nearly thirty cases in which Nowak-Vogl had documented giving minors epiphysan—more girls than boys, and most of them between the ages of seven and eleven. But records of the medication were erratic, and there was evidence suggesting that Nowak-Vogl had ordered its use in less controlled settings, including private homes.

Nowak-Vogl claimed that epiphysan was to be given only to children who were overcome by “instinctuality,” not to those who masturbated because of “neglect” or “neuroticism.” It wasn’t clear how children were sorted into these idiosyncratic categories. Patients—who were told little, if anything, about epiphysan—often regarded the shots as a punishment. At least one child understood that the extract was meant to suppress sexual urges, and refused it: In a report to a local youth-welfare office from the early sixties, Nowak-Vogl described, with frustration, a girl who had “countered the onanism treatment with a determined and conscious resistance.” The girl had insisted that she wouldn’t stop touching herself, because it “made her happy and otherwise she had it bad.” Nowak-Vogl lamented, “The known effect of epiphysan is by no means so strong that it could compensate for such an attitude.”

Nowak-Vogl, Friedmann told us, was willing to prescribe epiphysan even though almost nothing was known about its side effects. From what I’d read, Nowak-Vogl saw the drug as especially valuable for addressing social problems caused by female sexuality, including abortion and children born out of wedlock. Ideologically, her preoccupations placed her in the mainstream of postwar cultural attitudes in Austria, especially among traditional Catholics. Bodily shame has plagued many a childhood, but if the literature of Austria is any indication, that country was particularly thick with it in the twentieth century. The writer Thomas Bernhard, in his 1985 memoir, “ Gathering Evidence ,” describes being humiliated when his mother hung his urine-stained sheets out a window overlooking the street, “to deter other children, and show them all what you are! ” The work of the Nobel Prize winner Elfriede Jelinek plumbs the psychosexual depths of Austrian child rearing; in her 1983 novel, “ The Piano Teacher ,” the fiercely repressed protagonist, who is in her thirties, still sleeps in bed with her mother.

But, even in this context, the measures that Nowak-Vogl took were extreme. To justify the use of epiphysan, she relied on a panopticon-like system of surveillance that made it virtually certain every child would be caught touching herself. The squeak of a bedspring triggered reprimands over the loudspeakers, with the “culprit” made to stand in the hall for the rest of the night. (Nowak-Vogl was vexed that self-stimulation was hard to police in private homes, writing, “With little possibility of supervision, and possibly with the special skill of the pupil, there is a risk of overlooking this condition.”) Nowak-Vogl’s quest for an antidote to onanism was too haphazard to qualify as research, and she seems to have determined almost nothing concrete about epiphysan’s effects or complications. It would have been reasonable to wonder if the extract might damage a human’s pineal gland or interfere with puberty. Nowak-Vogl appears to have adopted an anecdotal, after-the-fact approach to information-gathering. Friedmann told us that, as late as 1980, Nowak-Vogl was asking former patients and their doctors if they’d noticed any health effects from the epiphysan that she’d administered years earlier.

Whatever risks the shots entailed were worth it, Nowak-Vogl wrote in her paper on hypersexuality. Without epiphysan, the only options for a girl who couldn’t stop masturbating were “accommodation on one of those very lonely, sometimes childless mountain farms, where all residents could be informed and reassured about the girl’s condition,” or placement in a sanatorium, which entailed “renunciation of further schooling.” As a chapter in “Psychiatrized Childhoods” notes, Nowak-Vogl acknowledged having performed an experiment on humans, but she clearly thought that she was improving society by eliminating undesirable behavior in children. Kids who didn’t explore their own bodies, or wet the bed, or talk or laugh or cry or run around too much, would grow up to become socially compliant workers. In a country whose economy had been shattered by the Second World War, her approach, however brutal, had its utility for the authorities.

To this day, there has been no systematic research into the long-term effects of epiphysan, but the expert commission reported that the extract has a short half-life, and is therefore unlikely to cause health issues in later adulthood. “Transmission of viruses” from bovine material can’t be ruled out, though nothing of the kind has been reported. In any case, Nowak-Vogl’s actions were certainly unethical, for she proceeded without the informed consent of either the children or their parents. Evy told me she was relieved that she hadn’t known of the epiphysan experiment until recently; it might have led her to avoid getting pregnant, for fear of complications or birth defects.

I asked Friedmann how influential Nowak-Vogl had been beyond the hermetic world of the child-observation station. It turned out that she had published and lectured widely, and had written popular advice manuals about child rearing. The Catholic Church awarded her a papal medal for her service in ecclesiastic marriage courts, which can grant annulments. “She really was respected,” Friedmann told us. “She was a full professor at the university.” Because Nowak-Vogl was also a consultant to the youth-welfare office, she could enter state-run orphanages and “recruit patients from there.” For nearly forty years, Nowak-Vogl’s beds were consistently full.

II–Curative Pedagogy

Nowak-Vogl was born, as Maria Vogl, in 1922 in Kitzbühel, a medieval town near Innsbruck which is popular with skiers. Her father, Alfred, was a juvenile-court judge. When the Nazis occupied northern Italy, from 1943 to 1945, Alfred presided over a Sondergericht , or special court, in Bolzano. Nowak-Vogl never wrote about her childhood, but, given her father’s role in the regime, she was likely steeped in Nazi conceptions of aberrance. Gerald Steinacher, a historian of Austria at the University of Nebraska-Lincoln, told me that the Sondergerichte existed to intimidate the populace and stamp out resistance, whether it be “a negative comment about the local Nazi leader or listening to Radio London.” Such courts, Steinacher said, “made a mockery of justice,” briskly issuing harsh sentences, including death.

During the war, Nowak-Vogl attended a Nazi-run teacher-training school. She studied medicine at the University of Innsbruck, and went on to receive a doctorate in educational philosophy there, in 1952. Six years later, she obtained a Habilitation —the highest academic qualification in many European countries—in the field of Heilpädagogik , or curative pedagogy. Throughout the German-speaking world in the early twentieth century, Heilpädagogik was an influential approach to treating “difficult” children. The goal of the field, which relied on close collaboration among medical experts, the courts, the state, the police, and the youth-welfare system, was less to help individual children feel understood than to turn them into productive, rule-abiding, sexually regulated members of society. Heilpädagogik had stressed biology from the beginning—inherited traits and inborn constitutions were seen as important reasons that children became resistant—but the Austrian school of curative pedagogy, which developed in the thirties, placed a particular emphasis on the hereditary component.

The celebrated physician Hans Asperger, known for his pioneering research on autism, became curative pedagogy’s leading exponent in Austria. Evy and I visited Herwig Czech, a medical historian in Vienna who, in 2018, revealed Asperger’s complicity in the Nazi regime’s eugenics policies. Heilpädagogik experts in Austria, Czech told us, had been eager to demonstrate the field’s compatibility with National Socialism, and also with the “strong authoritarian current” of Austrian Catholicism. Asperger had referred the most troublesome and mentally handicapped children to a Viennese institution, Am Spiegelgrund, where patients deemed “incurable” were killed.

Nowak-Vogl’s villa, Czech said, embodied the tenets of the Austrian school of curative pedagogy, with its relentless inculcation of “good” habits in children burdened by supposedly hereditary predispositions to alcoholism or crime, and with its unflinching willingness to remove kids from environments deemed undesirable. (Writing last year in Profil , an Austrian news magazine, the journalist Christa Zöchling decried “the disastrous history of curative pedagogy in Austria,” with its “dehumanization of children as ‘hereditary failures’ because they wet the bed or were left-handed, stuttered, or had learning difficulties or nervous conditions.”)

Nowak-Vogl shared with Heilpädagogik an unforgiving mentality toward sexuality—including toward children who had been sexually abused. According to Czech, the leading figures of curative pedagogy in Austria “turned against the victims somehow, by assuming that there was a kind of biological predisposition to being abused.” The idea was that a defective “personality trait led girls—mostly girls—to be practically seducing their abusers.” In 1952, Asperger wrote that young female victims of sexual violence often possessed “an endogenous willingness to experience” such assaults; some were “ ‘passive lure types’ who, above all, lack the natural protective mechanism of shame.” For such girls, he recommended a “long-term change of milieu, preferably placement in a good institution.”

In 1967, Maria Vogl married a psychiatrist in Innsbruck, Johannes Heinz Nowak, and hyphenated her name. They had no children. The couple apparently shared an interest in the rather grim wooden religious sculptures of a local folk artist. In the only video I’ve seen of Nowak-Vogl, from “Problemkinder,” a 1980 Austrian TV documentary about the abuse of children in institutions, she wears a starched white medical uniform and has her hair in a low bun. Leaning back in her chair and speaking in an emphatic tone, she defends her insistence on silence at the table: “There are quite a few children who, at home, aren’t allowed to talk with their parents at the table. There it is said, ‘Eat your meal first, then talk.’ So I think we are within the customary framework of the country.”

In Vienna, Evy and I met with Ernst Berger, a prominent Austrian child psychiatrist in his late seventies. He told us that, between 1975 and 1985, he’d often see Nowak-Vogl at psychiatry conferences. He described her as a “conservative woman, with her coiffure held back like this”—he mimed a bun. “She was very serious. And in dinner situations it was not very nice to talk with her.” Once, he said, after he’d finished a conference presentation of a paper criticizing the youth-welfare system, Nowak-Vogl had approached him in anger. “I didn’t know your work was so bad,” she said. Berger, laughing nervously at the memory, told us, “I was so frightened!” He had been aware that Nowak-Vogl ran a child-observation station in Innsbruck, but he’d never visited it. He didn’t know anyone who had.

Several months later, Evy and I tracked down someone who knew Nowak-Vogl’s child-observation station from the inside. In the winter of 1968, when Sylvia Wallinger was a nineteen-year-old psychology student at the University of Innsbruck, she began working at Nowak-Vogl’s institution. She had learned that it was headed by a distinguished academic who lectured on a subject that interested her: measuring concentration and memory in children. Wallinger stayed for about a year. She was looking for a thesis topic and had been told that she could conduct research under Nowak-Vogl’s auspices. Moreover, the child-observation station was around the corner from the house where Wallinger lived with her family.

When Evy and I contacted Wallinger, who is now a psychoanalyst, she was in the Canary Islands, where she lives part time, but she agreed to speak to us on Zoom. She wore pink lipstick and dangly earrings; shoulder-length silver hair framed her face. Though Wallinger is a practicing Buddhist, she didn’t seem particularly detached. She was clearly troubled by her memories of the child-observation station and expressed worry about upsetting Evy. Her empathy made Evy cry—the only time I ever saw her do so in an interview.

“The ice-cold showers—it was absolutely terrible,” Wallinger said. “When I did it myself, I used warm water. I was reported, and Nowak-Vogl threatened me, ‘Do what you’re told or just get lost.’ ”

The stories of two girls in particular had stayed with Wallinger: “The smallest had two thumbs cut—the tops were cut off. She was maybe five. Her father was a gynecologist who’d caught her masturbating, and he’d amputated one thumb and then the other.” The second girl, about eight, had accused her father of sexual abuse. “Because no father would think of doing something like this, it was she who was a compulsive liar,” Wallinger said, bitterly. “And, because she was a compulsive liar accusing her father, she was brought to Nowak-Vogl’s institution.”

Sometimes, when Wallinger worked at night, she’d hear girls crying in the communal bedroom, and she’d slip in and discreetly comfort them. But she typically took the morning shift, arriving at work in her white uniform just before the wake-up routine. “If a bed was dirty or wet,” Wallinger recalled, other children had to “stand around and make fun” of the miscreant. In the early twentieth century, a punitive approach to bed-wetting was common, including in America. Most experts gave little credence to the many developmental, physical, and emotional issues that cause a substantial minority of children to wet their beds past the toddler stage. Instead, children were sometimes thought to do it intentionally, out of laziness or defiance. Inventions such as the bed-wetting alarm could exacerbate the problem, waking up an entire household and shaming the unfortunate child. By the time that Nowak-Vogl was practicing her humiliating techniques, however, stigmatizing treatments were being discredited. She was a holdout.

When Wallinger worked at the child-observation station, Nowak-Vogl’s sister, Elisabeth, oversaw the kids’ schooling. Another figure in charge was a man called Höllebauer—Wallinger couldn’t remember his first name. She described him as “a brute” who enjoyed beating girls: “He was a physical sadist, and Nowak-Vogl a psychological one.” (During those years, a man named Robert Höllebauer, who had earned a Ph.D. in psychology in 1949, with a thesis building on Nazi racial theory, served as Nowak-Vogl’s deputy.)

Nowak-Vogl sometimes hit the children, too. “I saw it at least once,” Wallinger recalled. “A girl. She hit her around the face, and she fell.” But what troubled Wallinger most was Nowak-Vogl’s coldness: “She hated the children. She hated children . That’s why she did it. In a certain way, she wanted to destroy childhood in the children. She wanted to make them robots.”

When Evy told Wallinger about being forced to recount her dreams, Wallinger scoffed and said, of Nowak-Vogl, “Of course, that was not because she had any idea about psychoanalysis!” What had motivated her was “the inquisition—the intruding .”

Wallinger told friends about the horrible treatment of children at Sonnenstrasse. And then she confronted Nowak-Vogl, even though she knew that it would mean the end of her thesis and, possibly, of her academic career: “When I told her, ‘You cannot beat the children,’ she asked me, ‘Have you ever been at the B.D.M.?’ That was the Bund Deutscher Mädel—the Nazi organization for girls. They wore the brown jackets and the swastika.”

Wallinger protested: “Come on—I was born in 1948!”

“Oh, yes,” Nowak-Vogl said. “But if you had been in the B.D.M. you would understand what I am doing.”

A day or two later, Wallinger quit.

Throughout history, sadistic personalities have found cover—and even power and prestige—by directing their viciousness toward the furthering of a society’s goals. A psychiatric theory that sanctions ruthlessly authoritarian child rearing with the aim of producing biddable workers can license, and even glorify, the person who implements it. Nowak-Vogl exercised cruel dominion over children, but she always did so within the framework of academic expertise.

It was convenient for Nowak-Vogl that her commitment to repressiveness, sexual and otherwise, dovetailed with many of Austria’s anxieties after the Second World War. Authorities feared that war casualties had created a “surplus” of single women—a problem that seemed likely to worsen, given that divorce rates were climbing. Equally alarming was the thought that more women were having sex outside marriage. Politicians and journalists publicly fretted about venereal disease, particularly among women who had betrayed the fatherland by sleeping with Allied soldiers.

Austrians also worried that the deprivations of the war and its aftermath had fostered misbehavior in children. In an essay in “Psychiatrized Childhoods,” the political scientist Alexandra Weiss writes, “Absent fathers, difficulties of everyday survival, poverty, unemployment and bombed-out houses stood in the way of a carefree childhood and youth. . . . Parents were busy organizing everyday survival, children had to contribute to it and sometimes participated in semi-legal activities, such as the black-market trade.”

In the fifties and sixties, as Austria focussed on rebounding economically, the government of Tyrol placed more children in state institutions than during any period before or since—sometimes simply because a kid had a working-class single mother. In an e-mail to Evy and me, Horst Schreiber, the historian, described Nowak-Vogl as the kind of “inwardly frozen” figure who seemed to answer “a great social need” in postwar Austria: she was a credentialled expert implacably devoted to identifying the “rotten apples” of the lower classes and turning them into “proper bourgeois subjects, mothers and housewives, well-behaved family breadwinners who live the Catholic sexual morality, go to work, are not deviant, respect the authorities, love the homeland, and respect property.”

Even when Nowak-Vogl wrote about the importance of sleep for children, she managed to sound fascistic. In a 1964 essay published in English, she warned that children who tried to delay bedtime with mischief, or even thought of doing so, were guilty of “socially undesirable” behavior. By the seventies, Nowak-Vogl was also presenting her hypervigilant approach as an antidote to student-protest movements. In a contribution to a 1972 essay collection in which medical thinkers pondered the irksome question of why so many young people wanted to “revolt against society,” Nowak-Vogl suggested that a major answer was Vehrwahrlosung —neglect. In the framework of Heilpädagogik , the word implied more than social deprivation: it implied that a person had a moral or personality defect that made her vulnerable—for example, to sexual recklessness and sexual abuse. As Michaela Ralser, the University of Innsbruck professor, put it to me, this pseudo-diagnosis “transformed the child in difficulty into a ‘difficult child.’ ” A “neglected” youth, Nowak-Vogl wrote, was inclined “to oppose any trace of the old order, because it fails to completely indulge his overwhelming physical urges.” She warned that it was insufficient to discipline only youths who actively rebelled; more passive types could also become dangerous, unless “educational or therapeutic measures” were employed to thwart their opposition toward society.

Nowak-Vogl never expressed interest in one of the biggest sources of anger among young Austrians: cultural amnesia about the country’s Nazi past. In Germany, a reckoning with Nazism was hard to shirk, but many Austrians evaded responsibility by portraying their country as an Opfernation —victim nation—rather than as an enthusiastic participant in Nazi annexation. In fact, the Nazi movement had taken firm root in Austria: when Hitler’s troops marched across the border, in March, 1938, crowds welcomed them with flowers.

Immediately after the war, some Nazi war criminals did face justice in Austria—so-called people’s courts initiated tens of thousands of prosecutions and executed thirty perpetrators. Austrians who’d joined the Nazi Party—about ten per cent of the population—temporarily lost voting rights and, in some cases, jobs or property. But by the mid-fifties the people’s courts had been dissolved, and the Austrian government had abandoned de-Nazification programs. There was no substantive restitution for Austrian victims of Nazi atrocities, and the U.S., which was more concerned about Communism than about resurgent Fascism, stopped pressuring the country to ferret out war criminals.

The Opfernation mythology endured until 1986, when Kurt Waldheim, a former Secretary-General of the United Nations, ran for President of Austria. Journalists and historians uncovered evidence that, as a lieutenant in the Wehrmacht, he’d been attached to units that had sent thousands of Greek Jews to death camps and had executed Yugoslav partisans and civilians. Waldheim was elected despite these revelations, but the excuses that he’d offered—that he’d only been doing his duty, that he hadn’t understood the scale of the atrocities—repulsed many young Austrians in particular. In the mid-nineties, the government finally began compensating victims of Nazi war crimes.

By then, though, former Nazis had held positions of power for decades. Among them were doctors and psychiatrists who had run Am Spiegelgrund, the Viennese institution where Hans Asperger had consigned children and adolescents with disabilities. At Am Spiegelgrund, more than seven hundred children who suffered from psychiatric, behavioral, or physical conditions that the Nazis considered “incurable” were killed. The American historian Edith Sheffer, in her 2018 book, “ Asperger’s Children: The Origins of Autism in Nazi Vienna ,” wrote, “In Nazi psychiatry, a child needed to demonstrate conformity, ‘educability’ and ‘ability to work.’ ” She noted that “family and class factors played a role” in a child’s survival: “Chances of death were greater if the child was born out of wedlock, had an absent father, or a mother suspected of being unable to cope, with other children at home.”

Under the Reich’s T-4 program, the killing of institutionalized adults with disabilities had happened in gas chambers—the first instance of their use. But the “euthanasia” of children was accomplished slowly, by the very doctors and nurses caring for them. Children, Sheffer wrote, were “starved or given overdoses of barbiturates until they grew ill and died, usually of pneumonia.”

In 1946, a people’s court sentenced to death Ernst Illing, the head of Am Spiegelgrund, after he confessed to direct involvement in the killings of some two hundred children. His deputy, Marianne Türk, spent six years in prison. But these were exceptions. Hans Bertha, a key medical adviser to the T-4 program, was never called to account, and he became the dean of the medical faculty at the University of Graz. Hans Krenek, the “pedagogical director” of Am Spiegelgrund, later directed Vienna’s youth-welfare department.

If anything, Nazi psychiatrists, including those who sanctioned the murder of children, found themselves in a privileged position after the war. Many Jewish practitioners, including Sigmund Freud, had fled Austria in the thirties, and few of them returned; this exodus had opened up professional opportunities for Nazi scientists, many of whom, in addition to their ethical failings, were mediocrities in their fields. “Psychiatry, neurology, and pediatrics all had a high proportion of Jewish academics and practicing doctors,” Herwig Czech told me. “They left a huge gap.”

One survivor of Am Spiegelgrund remembered a physician named Heinrich Gross doing morning rounds in his Nazi uniform, handing out “sweets to some of the children, mainly the bed-wetters or the slow ones,” before they were taken away. In 1950, Gross was convicted of manslaughter by a people’s court, but the Austrian Supreme Court overturned the verdict for procedural reasons, and the case was never reheard. Gross became the director of his own neurological institute, where he conducted research on the preserved brains of children killed at Am Spiegelgrund.

He also became a highly paid court-appointed psychiatric expert. In 1976, Gross was hired to assess Friedrich Zawrel, an Austrian accused of stealing from a supermarket. Zawrel had been held in Am Spiegelgrund as a ten-year-old, mainly because he came from an impoverished family. Recognizing Gross, Zawrel said to him, “I know people who have committed crimes hundreds of thousands of times worse than mine. They are respected citizens.” When Gross appeared confused, Zawrel said, “Herr Doktor, you have a very bad memory. . . . Didn’t you hear the little children crying on the balcony? You never heard it—those who were murdered?” Gross took his revenge: he successfully recommended that Zawrel be confined to an institution for incorrigible offenders. From behind bars, Zawrel managed to unmask Gross to the Austrian media. In 1981, Zawrel was released, and prosecutors eventually brought murder charges against Gross. But he was deemed unfit to stand trial, and in 2005 he died a free man, at the age of ninety.

If Austrian psychiatrists who oversaw the murder of children were allowed to climb the professional ladder unimpeded, was it any wonder that Nowak-Vogl was, too? One of the child-observation facilities in Austria was run by Franz Wurst, a pediatrician who’d boasted of being the youngest doctor in the Reich. Wurst sexually abused children in his care; in the past two decades, hundreds of victims have come forward. But when he was finally arrested, in 2000, it wasn’t for this abuse—it was for his role in the murder of his seventy-eight-year-old wife. She had been suffocated, at his behest, by his nineteen-year-old godson, whom he’d molested over a period of years. (Wurst was sentenced to seventeen years in prison but was released after four years, for health reasons.)

Nowak-Vogl didn’t go wholly unchecked in the decades before Horst Schreiber and the University of Innsbruck researchers launched their investigations. Students protested her lectures because she brought in child patients and presented them to classes as case studies. In 1980, a director named Kurt Langbein made “Problemkinder,” the TV documentary, which exposed some of the disturbing practices at the Innsbruck villa, including the administration of epiphysan. The film was broadcast over the protests of conservative Tyrolean politicians.

Langbein, who is sixty-nine, grew up around concentration-camp survivors; his father, Hermann Langbein, an actor turned resistance fighter, was a political prisoner at Auschwitz and later wrote several books documenting his experiences there. Evy and I visited Kurt Langbein at his office, in Vienna, and he told us that, in making the film, he’d wanted to expose Austrian institutions “where the old Nazis were still working,” adding, “It was baggage from my father that I tried to carry properly.” His documentary had triggered some reforms at the Innsbruck institution. Nowak-Vogl had a new supervisor, Kornelius Kryspin-Exner, who ordered an end to the use of epiphysan (which, Kryspin-Exner acknowledged, “does not have any medical indication”) and to the restrictions on speaking (“the psychological value is zero”). But Nowak-Vogl remained an esteemed academic. Though she officially retired in 1987, she continued lecturing at the University of Innsbruck—on such subjects as “behavioral biology as a guide to educational crises”—until just before her death, in 1998, at the age of seventy-six.

Nowak-Vogl’s child-observation station remained in operation for seven years after “Problemkinder” aired, and it wasn’t subjected to further investigation until the two-thousands. Nevertheless, a new generation of mental-health professionals, some of whom had come of age with the student and feminist movements of the sixties and seventies, helped reshape the field of child psychiatry in German-language countries. Heilpädagogik was eclipsed by more child-centered, humane, and psychotherapeutic approaches. Closed institutions like Nowak-Vogl’s fell out of favor. The people who’d been trapped in them, however, still bore their scars.

III–Other Victims

On our first trip to Austria, Evy hadn’t wanted to meet other former patients of the Innsbruck child-observation station. She was determined to keep her memories of the villa distinct—and she didn’t want to speak German. But the more that her own recollections were validated the less fragile she felt. Learning the facts, she told me, gave her something powerfully “concrete”: “It’s not just Evy overreacting. It’s not just me making up stories, imagining things, lying—all the things I was told I did as a kid.”

When we returned to Austria, three months later, Evy was ready to meet, and offer help to, other victims of the psychiatric regime that had harmed her. We made plans to gather with some women who had been institutionalized under Nowak-Vogl. Austrian privacy laws—and a lingering atmosphere of shame—made it hard to find people who’d been confined at Sonnenstrasse. Many residents had spent the rest of their youths in orphanages or other institutions, and weren’t eager to revisit their pasts.

Horst Schreiber first heard about the child-observation stations from students he taught in an adult-education program, in the mid-two-thousands. The victims he met were initially reluctant to discuss their experiences, but, after he built a rapport with them, some agreed to be interviewed for his book. He offered to introduce three of them to us. Schreiber, who is sixty-two, has specialized in writing about uncomfortable aspects of Austrian society—the Nazi era, poverty, the children’s homes—and he has the merrily pugnacious air of a veteran gadfly. He rode a bicycle everywhere and talked so volubly that, at the Innsbruck café where we first met, one meal melted into another. His laugh was a torrent of high-pitched giggling that reminded me of Tom Hulce in “Amadeus.”

Schreiber nodded vigorously when Evy told him of the shame that she’d felt at “having been in a mental hospital like that.” She added, “You don’t even realize how strong it is, until finally a day comes when the tables are turned, and it’s ‘No, shame on you.’  ”

“This was the purpose of this institution—to shame,” Schreiber said. “And speaking in public—that helped a lot of people to not be ashamed any longer.” He took his scholarly obligations as a historian seriously, but he was just as serious about his moral obligations to the people whose stories he’d documented. He’d helped victims of Austrian institutions obtain their medical charts, organized commemorative events where victims could speak, and pushed for the creation of the expert commission that recommended reparations for former Innsbruck-station patients. One of them, Christine, was so appreciative of Schreiber’s work that she’d got a tattoo depicting the cover of his book.

Christine was among the three former patients who’d agreed to meet us and Schreiber for lunch, at a restaurant at the foot of a mountain west of Innsbruck. She and the other two, Heidi and Hanni, had become friends, and in front of the restaurant the women greeted one another warmly. Then they did the same with Evy.

We sat down at a long table outside a traditional whitewashed building with dark-wood shutters and beams. Below us was a green meadow bright with sunshine. Rivulets of melted snow ran down the craggy mountains, glittering like silver chains. We stayed there all afternoon, alternating between beers and coffees, spätzle and salads. Christine was funny and outgoing and fidgety. She wore a rainbow-striped sleeveless top and bright-blue eyeliner. She showed off her book-cover tattoo—it was on her right leg—and warned me against a Tyrolean specialty on the menu, unappetizingly described as gray cheese, which she then ordered.

Like Evy, the three women had, in addition to the child-observation station, spent time in other harsh institutions and in foster care. With truncated educations and traumatic upbringings, they’d had challenging lives. But each woman said that the villa had particularly haunted her. All three remembered the suffocating imperative of silence, the minute monitoring of their movements, the enforced lifelessness so inimical to a community of children. Heidi told us that she’d come from a lively, loving home; her mother, who was Romani, was not “a typical Austrian hausfrau in an apron”—she’d strung up fairy lights in their back yard, played the mandolin, and loved to dance. One day when Heidi was eight, she came home from school and found that her mother had forgotten to leave a key under the doormat. Night fell, and she and her older brother went to a police station for help. Child-welfare officials immediately picked them up and separated them; she didn’t see her brother again for twenty-seven years. In a recording that Heidi had made with Schreiber, she said that the worst thing about Nowak-Vogl’s institution was the “complete ignoring of the inner life—the soul—of the child.”

Hanni, who wore a flowered dress and pearls, had short gray hair and a soft, sympathetic face. At seventy-one, she was the oldest of the three, and she said that she’d been confined at the child-observation station multiple times—starting at the age of two. When she had difficulty learning her colors, Nowak-Vogl beat her. She remembered voices booming out of the loudspeakers the instant a child spoke: “ Quiet! Quiet! ”

Christine said that she’d never seen a loudspeaker before arriving at the villa, at the age of six, and had believed that the voices were ghosts.

Evy leaned toward each woman in turn, placing a consoling hand on hers. She had switched to German—none of them spoke English, and it was worth it to her to communicate directly. They all had children, and shared the kids’ names and ages. Wind rippled the shimmering leaves on birch and aspen trees. Fat bees buzzed around the sudsy glasses on the tables. One stung Schreiber on the mouth as he sipped beer, and Christine dug around in her tote bag for a salve. Somebody asked about nightmares and flashbacks. Heidi, who wore a moss-green dress and smoked cigarette after cigarette, volunteered that Christine had suffered the most flashbacks, because “she doesn’t have the peace she needs to mentally work through everything.” Christine then explained that the stigma she’d internalized as a child made her feel responsible for troubles her own children were now experiencing.

They talked about their medical charts, which were a confusing business. Nowak-Vogl had devised her own diagnostic code, using letters, and nobody had completely cracked it. Notes on the charts were a mixture of harsh judgments (kids were deemed “lazy” or “sneaky” or “slobs”) and psychological jargon, some of it imported from psychoanalysis (children had “neurotic” or “Oedipal” tendencies). Evy’s chart identified her as suffering from a jealousy of her foster sister which could be either “psychopathic or neurotic.” She was also deemed a “gossip” who sucked her thumb, wet her pants, and lifted her skirt to fix her underwear. It was noted that she had once spilled water on another girl’s bread, and had “probably bent a tulip” in a garden but “didn’t admit to it.”

When we’d come across the line about the tulip, Evy said, “There was no winning in that environment.” The tiniest act was turned into a negative “judgment on your character.” Any errant behavior that Nowak-Vogl observed was attributed to inborn deficiencies. The institution was seen as an objective diagnostic machine, and nobody in charge seems ever to have reckoned with the distorting behavioral impact of ripping children from their homes and dropping them, without explanation, into a frightening new reality. Instead, the researchers condemned Evy for her “clinginess.”

A consistent theme in Evy’s chart was her torment over being abandoned. A typical entry observed, “She wants to be noticed and is always afraid that she’ll be forgotten at home.” The chart noted that Anni, Evy’s foster mother, hadn’t sent letters or packages regularly.

Most victims who reviewed their charts couldn’t help but be rattled by them. One woman had told Schreiber that reading hers had been “shocking” because it made her seem, at four years old, like a “sex monster.” Georg Kaser, another former resident at the child-observation station, who met with Evy and me on a Zoom call, had ended up at Sonnenstrasse when he was ten. He came from a happy home, but he had developed anxieties—panicking, for example, when he sensed that his heart might be beating strangely. At the villa, he was miserably homesick, but this was construed as yet another indicator of constitutional weakness; his chart noted, with evident distaste, that he cried at night and was “always seeking attention with his loud voice,” or else staring “straight ahead,” looking “depressed.” Outwardly, Georg could make a good impression, but in secret he was “always up to something,” and had “a craving for validation.”

Georg is now an actor who runs his own theatre company. He has three adult children, and he proudly showed us photographs of them. He wore hip yellow glasses, and seemed charming and at ease on the Zoom call, though he said that he had suffered from anxiety throughout his life. He had been curious to get his chart, but reading it had taken him aback. All the things that he remembered as most salient about the place—being locked in the cellar, being forced to eat bits of fat he’d left on a plate, watching a boy who had difficulty dressing himself be paraded around and humiliated by the staff—went unnoted.

Evy’s file didn’t mention therapies. The authors of “Psychiatrized Childhoods” argue that the “most striking” quality of the charts is that “treatments were rarely named” and “their success or failure hardly reported.” The charts create “the impression of a certain arbitrariness.” Talk therapy certainly wasn’t offered. Hanni and Christine said their records indicated that they’d been given epiphysan. Georg’s chart mentioned that he had been given barbiturates, but noted nothing about their effects.

Heidi said her chart noted that she’d talked back to Nowak-Vogl, demanding to know why she was there, how long she’d be there, and where her brother was. Reading her file, she felt that she had been disparaged for being a child nicht auf den Mund gefallen —a blabbermouth. Though Nowak-Vogl grudgingly noted Heidi’s intelligence, she recommended that she be sent to a Catholic home, where she ended up working in the laundry instead of attending school. (Despite this, Heidi managed to have a rewarding career, as a legal secretary.)

Ina Friedmann, the historian of medicine, told me in an e-mail that the sedatives appear to have served mainly to “guarantee the functioning” of the child-observation station from day to day, by preventing “ ‘wild’ behavior.” Again, neither Nowak-Vogl nor her colleagues seem to have noticed that their scientific observation of children was being tainted by the constant drugging of their charges.

When it was time to head back down the mountain, Evy thanked each woman. Remembering Sonnenstrasse had been such a lonely experience for so long, she said. Evy told them that she wanted the Tyrolean government to make a bigger effort to find people who were entitled to an apology and to reparations. There had been a flurry of attention in Austria a decade ago, when the commission report came out, but evidently many victims had missed the news. Why wasn’t there a comprehensive Web site that laid out all the necessary information, including ways for victims to connect with one another and with therapists? If the government wouldn’t create one, Evy decided, she would do it herself. To date, four hundred and fourteen former patients at Nowak-Vogl’s institution—less than twelve per cent of the total—have come forward to report being abused.

IV–Family Secrets

Learning the truth about the villa soon led Evy to other discoveries, about her family and Austrian history. She hadn’t expected so much to fall into place, and I sometimes saw her shake as if an electric current were running through her—from the force of revelations and memories, and from anger at officials who tried to withhold information or questioned the value of revisiting the past.

As Evy now recognized, she had once taken refuge in this attitude herself. She’d left the country the year after graduating from hotel-management school, in 1984, and had never considered returning home. For seven months, she worked as a wine steward on a cruise ship in the Caribbean. But she tired of all the drunk tourists, and when the ship was docked in San Juan she and a co-worker decided to quit their jobs and fly to Miami. When they got to the airport, the last flight for Miami had already taken off, but there was one leaving for New York. Evy got on it.

She instantly felt comfortable in the city: for the first time in her life, she wasn’t relentlessly “judged for being different.” She was just shy of twenty-one and didn’t know Manhattan from Brooklyn or Queens. But she cobbled together a new life, loving the anonymity offered by a city as big as New York, where your past didn’t have to trail you like the clattering cans on a newlywed couple’s car. She initially stayed at the Y.M.C.A. on Forty-seventh Street and worked random jobs: scraping plaster for an apartment renovation, waiting tables in the Village. She once waited on Uli Edel, the German film director, who was then making “Last Exit to Brooklyn,” and they dated for a while. She befriended a bald, bearded man because she thought that he was the writer Shel Silverstein; he wasn’t, but over diner breakfasts he told her stories about the gay S & M scene.

One day, Jimi, the bar owner from Kleinwalsertal, and her husband, Andi, had the inspiration to send Evy a camera as a gift. Evy had never had one before, but she loved it right away, and roamed the streets taking pictures. She signed up for classes at Parsons and at the International Center of Photography, and became a devotee of Dorothea Lange. Her first published picture, of striking workers at LaGuardia Airport, ran in a leftist New York weekly called the Guardian . “I thought it was very much like Dorothea Lange!” she said, laughing.

She started freelancing for Agence France-Presse, then got a job with Reuters. In 1993, the Daily News hired her. It was a boys’ club, but a friendly one. She’d receive a gruff directive—“Go to the East River, there’s a floater”—and bicycle across town to get the shot. She won recognition for her work, and in 2000 she was named photographer of the year by the New York Press Photographers Association. One evening, on assignment for the paper, she was flying over the Brooklyn Bridge in a helicopter at sunset. The East River was glowing orange, and as she leaned out to get some shots she began sobbing: “I thought, I’m in New York—I’ve made it. But I couldn’t tell anybody how far I’d come.”

Though she was determined to escape her past, it kept resurfacing. “I was just haunted,” she told me. “I couldn’t sleep with the lights off.” Sometimes she became so panicked on the subway that she had to run off the train wherever it stopped next. The photographer Greta Pratt, who was her boss at the Reuters bureau in New York and became a close friend, told me that Evy was vivacious and driven but also “secretive, because she was so hurt inside.” Pratt recalls that Evy would “just sort of turn and walk away” from anything that conjured upsetting associations. When Evy was in her twenties, she developed a profound eating disorder—she sometimes passed out from hunger. But her experience of psychiatry in Austria had been so horrific that seeing a therapist felt impossible.

During this time, however, she began dating her future husband, Paul Schwartzman, a New York native who came from a family of therapists. He encouraged her to seek help, and she began seeing a specialist in eating disorders, who warned her that she might die in her forties if she didn’t stop starving herself. With the therapist’s coaching, she stopped. When I asked Evy why she hadn’t been able to confide in the therapist about the villa, she said that the pain “was way too deep,” and that her mentality at the time was “You’re just trying to patch yourself up so you can walk down the street.”

Evy had long accepted that she had no family—she’d never tried to track down her biological parents. But one day in 1995 she received a phone call from a sister she hadn’t known she had. Her name was Barbara Wespi—her friends called her Barbarella—and she was a year younger than Evy. They had different fathers, and Barbarella had met their mother only a few months earlier. Their mother was named Evy, too. The sisters agreed to meet in Switzerland, where Barbarella lived. At the airport in Zurich, Evy was so nervous that she didn’t want to get off the plane, but once she caught a glimpse of Barbarella—whose smile was as wide and radiant as her own—they stood pressing their hands on either side of a glass dividing wall, weeping.

Their relationship with the woman they soon dubbed Evy, Sr., started off promisingly, too. Evy, Sr., said she was overjoyed to finally have her daughters in her life. She explained that Evy’s father was a young man with whom she’d had a short relationship in 1964, when she was twenty-one and working at a restaurant in Salzburg. Evy, Sr., had gone to the city hoping to be an extra in the summer opera’s production of “Elektra”; the young man was studying art at the School of Seeing, an avant-garde institution founded by the Austrian painter Oskar Kokoschka. Evy’s father had been sweet and intelligent, with curly chestnut hair and beautiful eyes. He had also been determined, tough, and energetic—qualities that Evy, too, seemed to possess. Barbarella’s father had been a one-night stand whom Evy, Sr., had met while working at a train-station restaurant in Switzerland. She said, apologetically, that she couldn’t remember either man’s name.

Evy, Sr., told her daughters that she had been born in Innsbruck in 1943. Her father had been a Jewish wholesaler of shoes. In 1949, he died. In those immiserated postwar years, her mother, overwhelmed by the need to make a living, sent little Evy, Sr., and her brother, Jürg, to live in a convent school outside Paris. She died not long afterward. Evy, Sr., lived briefly with her grandmother, then in group homes. In her late teens, she became itinerant. When she was still a minor, the police in Marseille arrested her for prostitution—a false charge, she insisted—and sent her back to Innsbruck, where she was institutionalized for a time. Her life had continued to be peripatetic, but now she was settled down, in a village in the Italian Alps, with a retired Italian construction worker.

Evy was openhearted and curious about her mother, and felt connected by their shared experience of orphanhood. But their connection soon faltered. Evy, Sr., visited Evy and Paul in New York, but to Evy she seemed detached and unenthusiastic. After returning to Italy, she sent letters, but they often consisted of bland comments about the weather, and she evaded further questions about their family history. “It drove Barbarella and me crazy, because we wanted some real answers,” Evy told me. “And it didn’t feel like she had true curiosity about us . I’m sure it came from a lot of pain. She was a very hurt person, and that’s how she dealt with her trauma.”

Evy let their correspondence lapse, and by the early two-thousands she’d stopped communicating with Barbarella, too. In 2018, Evy received a call telling her that her mother had died.

By the time Evy and I began investigating her personal history, her adventurous older daughter, Stella, had just started college, in Paris, studying art, and she had expressed an interest in meeting Barbarella, whom Evy hadn’t been in contact with for years. Evy began tentatively e-mailing and texting Barbarella, saying that she was sorry to have been such a disappointing sister. “You’re the sister I want,” Barbarella told her. Evy asked to communicate in English, and Barbarella agreed. “That opened up the opportunity completely,” Evy told me. “Just to be accepted like that. And I think, in a strange way, if I’m totally honest, it helped when I found out the truth about Innsbruck. It was, like, ‘Maybe if I share this with my sister, she’ll understand why I’ve acted so fucking weird.’ And she did.”

Evy, Stella, and Barbarella met up in Paris in November, 2021. Barbarella, who is gay and has no kids, turned out to be an ideal long-lost aunt: she was affectionate and funny with Stella, and, like Evy, she was unfazed by teen-agers’ roiling emotions. Barbarella had worked as an art restorer and as a club d.j., and now owned an interior-design business in Zurich, where she had a close-knit crew of friends.

As a baby, Barbarella had been adopted by a Swiss couple in Horn, a small town on Lake Constance. The couple, who had previously adopted another daughter, soon divorced. The older girl had schizophrenia and was at times violent, and Barbarella had found it impossible to sustain a relationship with her. When Barbarella had first got to know Evy, all those years ago, she’d said to herself, “Oh, it wasn’t my mother I was looking for after all. It was you.” She told me, “Finding and losing Evy was difficult to understand. I tried to lock my heart and walk away, but it wasn’t possible. My heart told a different story.”

Barbarella joined Evy and me on our two trips to Austria. The first time I met her, in Innsbruck, she ambled over wearing red plaid stovepipe pants, black Converse high-tops, and an oversized sweater bearing the phrase “ Je ne sais quoi .” On the second trip, Sammy and Stella, who were on summer break from college, and Lily, who was in high school, came, too. After gathering in Innsbruck one afternoon in July, we headed to a building that houses the Tyrolean state archive.

The archive had a fat file on Rudolf Mages, the maternal grandfather of Evy and Barbarella. Their mother’s portrait of him was false. Rudolf hadn’t been Jewish—he had been a Nazi, and such an eager Party member that he’d signed up in 1931. He’d gone to prison at least twice for Nazi political activities during the period between 1934 and the Anschluss, when Party membership was illegal in Austria. He’d fled to Munich when there was a crackdown on Nazis, and had been extended refugee status in Germany. Rudolf had held one of the highest honors the Party accorded—membership in the Blutorden, or Blood Order—for his devotion to the cause. In 1938, he and his wife, Herta, had “Aryanized”—taken over—an Innsbruck shoe store belonging to a Jewish proprietor, Richard Graubart. Later that year, during the November pogroms that broke out across the Reich, S.S. men found Graubart at home with his wife and four-year-old daughter, and stabbed him to death. These were bewildering discoveries. Had Evy, Sr., been lied to? Or had shame led her to conflate her father’s identity with that of a Jewish man he had victimized?

With horror, Evy realized that the course of her childhood was partly attributable to the fact that her troubled mother had been raised by active Nazis. It was not a hereditary burden, of the kind that Nowak-Vogl had believed in. It was a historical burden.

She kept going through the archive’s sepia-toned pages, as Sammy looked over her shoulder. In 1943, the file revealed, Rudolf had served a short time in prison for war profiteering—selling shoes without the proper ration certificates, and hoarding goods. Evy sighed in exasperation and said, “This is 1943, right? And you don’t go to jail for murdering people, or for stealing somebody’s whole life and property. But you do go to jail for selling shoes without a voucher.”

Evy and Barbarella held out hope that Herta, Rudolf’s wife, had been at most a reluctant participant in all this. Their uncle Jürg was still alive, in Germany, and Barbarella was in contact with him. He believed that Herta had divorced Rudolf after the war because she no longer wanted to be married to a Nazi. It wasn’t clear to Jürg, though, why Herta had sent him and his sister to the convent school outside Paris. Perhaps she had been shielding them from their father’s ignominy?

A few months later, we got closer to an answer. Evy, who had asked another Innsbruck archive if it had anything on Herta’s family, received a reply from a historian and archivist named Niko Hofinger. Evy’s timing had been fortuitous: in the basement of the city’s police headquarters, somebody had just discovered a bunch of files from the Nazi period. The cache included a file on Herta. Evy might not like what she learned, Hofinger warned.

Evy asked to see a copy, and a PDF arrived in her in-box. It painted a picture of a woman out of Fassbinder’s postwar trilogy: tough, cunning, and alluring. Like Maria Braun or Veronika Voss, Herta seemed to have traded on her looks, curried favor with Nazi leaders, and aggressively worked the black market. In 1936, according to an account that she’d given to the Innsbruck police, she’d lost her job as a salesclerk at a Viennese jewelry shop because of work she’d been doing for the then illegal Nazi Party: printing Party newspapers, making explosives. She married Rudolf, who was fourteen years her senior, in 1937, when she was twenty. A bookkeeper for the shoe store that the couple Aryanized described Herta as a “charming” woman whose “morals were not exactly impeccable,” adding, “It was well known that she had several lovers. She had nothing left for her children. They were a burden.” Herta, the bookkeeper said, had a “close connection” with Franz Hofer, the region’s highest-ranking Nazi, and could call him at any time on a secret number. Rudolf used his wife’s connections to Nazi officialdom to finesse business matters.

After the war, Rudolf was held in an Allied prison. Herta divorced him, and placed their kids in the French convent school. She moved into an apartment in Kitzbühel, where neighbors resented her lively parties and lavish life style. She travelled often to Milan and to Paris, where she sometimes visited her children. Police records indicated that state and border police had monitored Herta for suspected smuggling of furs (including a “monkey-skin cape”), paintings, antiques, and, possibly, cocaine.

In 1949, Rudolf killed himself, slashing his wrists in a guesthouse in Innsbruck. Herta died three years later, at thirty-five, apparently of a heart attack.

Evy shared the file with Horst Schreiber, who said that Herta came across as, if nothing else, a “clever” woman who had “seized favorable opportunities by the scruff of the neck.” Still, Evy could find nothing to suggest that Herta had cared much for her kids.

Negligent parents come in all ideological stripes. And Evy, Sr., might have struggled psychologically wherever and whenever she was born. But her childhood had clearly been warped by her parents’ Nazi activities—and by her mother’s decision to send her to a foreign country. Evy found herself feeling more compassion for her mother than she had when she’d known her.

Moreover, they had both been abused by doctors. After Evy, Sr., was arrested in Marseille, she had undergone electroshock therapy at a hospital outside Innsbruck. Electroshock was widely practiced in Europe and the United States in the postwar years, though it was usually indicated for intractable depression or schizophrenia, not for young women who might have been engaged in sex work. Evy, Sr.,’s memories of the experience had been unusually detailed. She’d described waiting her turn and seeing other patients convulse as electricity was administered. She remembered a Dr. Rodewald and a Dr. Simma, noting that Simma had a wide mouth that reminded her “of a toad’s.” (Official records indicate that psychiatrists named Hermann Rodewald and Kaspar Simma worked at Valduna, a hospital near Innsbruck, after the war.)

Evy and I tracked down a journalist named Hans Weiss, who, as a psychology student conducting research at Valduna in the seventies, had known both doctors and had witnessed electroshock procedures. He confirmed that patients awaiting treatment could see and hear what was in store for them. Patients were supposed to be given anesthesia, Weiss said, but some weren’t—apparently as punishment.

Shortly after we returned from our first visit to Austria, Evy learned that her foster mother, Anni, was still alive. She was in a nursing home in Kleinwalsertal, and in her nineties, but, according to Evy’s contacts in the town, she was able to receive visitors. Evy had decided to confront her on our second trip. She initially hesitated about including her kids in this particular encounter. But they were growing up, and they were curious. “It was always something I wanted to shield them from,” Evy told me. “But then it’s like you create secrets. And I don’t want secrets.” She concluded that treating the trip as “an investigation into something that happened in their family tree” might give them power over the story, and insight into the intimate ways that history works itself into us all.

To get to Kleinwalsertal, we took a train from Vienna to Munich, then a smaller train to Memmingen, a third train to Oberstdorf, and, finally, a bus over a mountain pass. It was high summer, and hikers with walking sticks passed through the town on their way into the Alps. We got cheese sandwiches at a café, then headed to the nursing home for an unannounced visit.

Anni sat teetering on the edge of a bed, a small, thin woman with lank white hair and a creaky, plaintive voice. But she seemed to recognize Evy, who knelt in front of her and said, “Anni, do you remember my childhood?”

“I have to think far back,” Anni said. The conversation proceeded in fits and starts, with Anni looking into Evy’s eyes and gripping her arm. “You rejected me,” Evy said. “You didn’t love me. You treated me terribly. You locked me in a cellar. I’m glad I get to tell you this.”

“You can tell me everything—all the things I did wrong.”

“It hurt me a lot, for many years.”

“I am sorry,” Anni said. “The sorrow is real.”

For Evy, the encounter was draining and disorienting. The monster of her childhood had become a vulnerable, feeble woman who, for the first time in Evy’s life, seemed to want her company. Evy briefly veered away from dark topics, informing Anni that she was now a photojournalist in the United States. They chatted about Anni’s daughter, who now lived near Munich.

Suddenly, Anni wept, dabbing her eyes with her shirt. Evy turned to us and said, “Does somebody have a napkin for her?” She couldn’t help but react with solicitude. Lily was kneeling next to her mother, with an arm around her. Sammy stood on Evy’s other side, with his arms crossed across his chest, glowering. Stella sat at a distance, tears streaming down her face.

Evy asked Anni why she’d sent her to the villa. Anni replied that a doctor in the village had known of Nowak-Vogl’s institution, and had recommended it. Evy said that Nowak-Vogl had been “very brutal,” and asked Anni if she’d known her reputation. “No,” Anni said. She told Evy, “We have both the same sorrow. You have it, and I have it. And we can’t run away from it. That doesn’t work.” Evy and Anni hugged, crying.

Anni’s daughter doesn’t recall her mother being unkind to Evy. But that evening our group met up with Anni’s nephew Heini, who had lived up the hill from Anni’s B. and B., and he remembered vividly Anni’s hostility toward Evy. He said that he wished his family had done more to stop it.

It wasn’t clear how much of the nursing-home conversation Anni had taken in, but Evy felt some satisfaction in finally having the upper hand. By turning up with her “beautiful family,” she told me, she had shown Anni that, despite her foster mother’s mistreatment, she had thrived.

Stella put it more bluntly: “The best revenge Evy got was how great a mother she is.”

Earlier this year, Niko Hofinger, the archivist in Innsbruck, informed Evy that a city archive likely contained a file documenting her time as a ward of the state. Evy successfully pushed for permission to see it. A letter from Robert Höllebauer, the brutal psychologist who worked alongside Nowak-Vogl, said Evy’s stay at the villa had established that she was “neurotic,” and that if she continued to create disturbances in her foster family she should be dispatched to one of the small children’s homes known as SOS-Kinderdörfer. On these terms, she was returned to Anni, who, Evy recalls, made a point of telling other children in the village that she had just come back from a mental institution. Anni told a child-welfare official that, though Evy had been more restrained since her return from Nowak-Vogl’s, she was still committing “malicious acts.” Evy tried desperately to please Anni, but a letter from the official noted, “Her high spirit must constantly be dampened.” If Anni had wanted a quiet playmate for her daughter and an efficient helper—both girls were expected to clean guest rooms and do other chores—Evy was not that.

The file also contained notes from a caseworker, which said that Evy wanted Anni’s affection, and tried to do what was expected, but was rambunctious. As we read through the assessment, Evy told me that she had skied recklessly as a kid. Once, she was entrusted with bringing a tall votive candle home from church; she dropped the candle, breaking it. She resented being the butt of jokes, and hated certain local traditions, such as when the terrifying Krampus came to the door in December, threw “bad” children in his sack, and carried them out into the snowy night. Evy got upset when she was forced to sit on the “donkey bench” at school with the only other child deemed an outsider—a Turkish boy. The school’s principal recommended that she be sent away again, as soon as possible, because she outshone Anni’s daughter academically. This, apparently, is why Evy ended up in the orphanage in Germany: she had been too smart for her own good, and her high spirits had proved incurable.

In the file, Evy discovered a record of her birth, and on it was written something that she’d never expected to learn: a father’s name. One morning, she texted me a photograph of a handsome, brooding man who bore a resemblance to the actor Joaquin Phoenix. “I think this is my father,” she said. He was Othmar Zechyr. On the document, Evy, Sr., had provided his birth date, May 28, 1938, and his birthplace, Linz. Looking him up, we saw that, just as Evy, Sr., had told her daughter, he had studied at Oskar Kokoschka’s art school, in Salzburg. Zechyr had become a well-known artist in Austria, with work in major galleries and museums. He had made moody, crosshatched pen-and-ink drawings—of knolls and haystacks, of fantastical machinery. Zechyr, who died in 1996, had three children. Evy is now in correspondence with one of them, an art historian in Vienna. She has broached the idea of confirming their mutual paternity with DNA tests, and of meeting in Austria.

At the end of the file was an official’s assessment of Evy as a teen-ager: “The minor is courageous enough to assert herself in life.”

Evy had Austria, and the German language, back in her life now. She had befriended advocates, historians, and former victims who were dedicated to an honest reckoning with the past. She had a renewed relationship with Barbarella. She had a probable candidate for her biological father, someone whose art she very much liked. She felt greater sympathy for her biological mother. There was only one more thing she wanted to face.

From the outside, the villa on Sonnenstrasse was basically as she remembered it: a rather grand and solid-looking structure from 1914, painted pale yellow. It was now divided into private apartments, with a locked front entrance, and to get inside we haphazardly pressed the buzzers. An older man named Peter, who lived on the top floor, let us in.

Nowak-Vogl’s institution had moved to a new location in 1979, and afterward the villa sat empty for years. Trash piled up inside. Then, one day in 2003, the villa underwent a strange rebirth. A group of young punks started squatting there. They cleaned it up, showed movies and put on concerts, and took in anarchists, homeless people, and runaways, including kids fleeing abusive families from all over Europe. They nicknamed it Villa Kunterbunt, after the German name for Pippi Longstocking’s house, where she lived on her own with her monkey, her horse, and her books.

One day, a young punk named Ingo spotted a man in his forties lingering in the garden, staring at the windows. The man explained that he’d been confined there as a child. Ingo invited him in and let him see his room. The man began trembling and crying. Ingo’s room had once been the office of the institution’s director, the man told him, and he had been so scared of her. Until that day, the squatters didn’t know the villa’s history, but they weren’t entirely surprised. Although many of them had lived in more decrepit places, this one had the air of a haunted house.

Ingo now works for an organization in Innsbruck that helps homeless people. When Evy and I found him, we were back in the U.S., but he agreed to meet us on Zoom. He showed us photographs from his time in the villa. “It’s amazing to see different images from what you hold,” Evy told him. “It kind of pushes back against the bad shape of what happened there.” Villa Kunterbunt hadn’t been perfect—there were police raids and hand-to-mouth struggles, and in 2005 the young people were evicted. But they had cared for one another and had made a community whose spirit of love and freedom was antithetical to the rigidity and surveillance of Nowak-Vogl’s institution. The transformation of the villa seemed to Evy like a benediction.

When Evy and I entered the building on Sonnenstrasse, she felt afraid but also ready. In the foyer, shafts of sunlight illuminated white walls and an imposing curved staircase, which looked very familiar. “I felt like a dragon slayer, going inside that building,” Evy said the next day. “I never could have imagined doing that.” On the villa’s first floor, she looked up in silence. She touched the walls. Then we turned around and walked back out to the street, where her children were waiting. ♦

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Evidence-Based Design for Waiting Space Environment of Pediatric Clinics—Three Hospitals in Shenzhen as Case Studies

Associated data.

The data presented in this study are available on request from the corresponding author.

This study explores the waiting space environment of pediatric clinics in general hospitals and the relationships between the use of space, behavioral activities and overall satisfaction. Patients often spend a lot of time waiting for doctors, and child patients waiting to be seen are particularly likely to feel bored, depressed and anxious, which negatively affects their overall experience of seeking medical attention. Since the launch of China’s second-child policy, the number of children born in China has surged. As medical resources for children are in short supply and of uneven quality, it is urgently necessary to carry out research on optimizing the design of children’s waiting space in Chinese hospitals to improve their medical environment and experience. Method: This study identified four first-level indicators and twenty-seven second-level indicators in four dimensions: functional layout (layout and area), flow organization, supporting facilities and environmental details (physical and landscape environment). The research combined subjective and objective methods, including comprehensive observation, a questionnaire survey and interviews, taking three hospitals in Shenzhen as case studies. Results: The study found that the waiting space in pediatric clinics currently fails to meet key patient needs in areas such as mother and infant rooms, children’s play areas and drinking water facilities, and there are widespread problems with the creation of natural environments, such as views of natural scenery from windows and indoor green plants. Six factors were found to significantly positively influence overall satisfaction with waiting space, describing 69.76% of the changes in the respondents’ degree of satisfaction with the waiting environment. Supporting facilities and aspects of the physical environment had the greatest influence on overall satisfaction with the waiting space. Conclusion: Optimizing the design of the waiting space in pediatric clinics, with a focus on functional layout, flow organization, supporting facilities and environmental details, can improve overall satisfaction with pediatric waiting rooms. The results are preliminary; they need to be further tested in practice to complete the process of evidence-based design. This will lead to suggestions for refining the design of pediatric waiting units which can be used by architects and hospital administrators.

1. Background and Research Goals

1.1. evidence-based design.

Evidence-based design originated from evidence-based medicine and is now a mature theoretical system. The basic goal of evidence-based design is to prudently use the best available evidence from multiple sources or parties to make design decisions. According to supportive design theory, a good medical environment design can alleviate patients’ pressure [ 1 ]. Design goals include exposure to nature and art and appropriate ceiling design, acoustics and color. Supportive design theory is applicable to childcare settings [ 2 ]. Providing positive resources and conditions, such as control, distraction and social interaction, can reduce or even prevent children’s environmental stress [ 3 ]. A well-designed physical environment can help patients achieve better treatment results [ 4 ].

• (1) Functional layout

A large and spacious waiting room may increase patients’ perceptions of care quality and comfort, as well as their overall satisfaction [ 5 ]. Conversely, a crowded waiting room can increase patients’ annoyance and degree of pain [ 6 ]. However, privacy is also a crucial element of waiting room design. When social interaction is not required, a large space may seem to lack privacy [ 7 ]. Studies have shown that users prefer waiting rooms with self-help family resource centers [ 8 ] and children’s play spaces, to help meet children’s psychological needs [ 9 ].

• (2) Flow organization

While waiting for medical attention in a pediatric department, patients may need to use the restrooms, drinking water facilities, spaces for children and other supporting functional facilities. The ideal hospital layout minimizes patients’ transfer distance [ 10 ]. Space syntax is one of the most widely used design toolkits in this context; it aims to simplify users’ wayfinding in healthcare centers [ 11 ]. The distance from the waiting area to the consulting room and the number of intersections are important determinants of wayfinding. Design elements such as symbols, permanent signage, printed materials, landmarks and architectural features provide assistance for wayfinding [ 12 , 13 ]. Rich colors may also help users to identify specific parts of the building [ 14 ] and flowline the organization of space.

• (3) Supporting facilities

When waiting for medical attention, being able to sit next to one’s companions, such as friends or family members, is extremely important [ 15 ]. In the wayfinding system, signs, maps, display boards, information desks, furniture, color-coded pathfinding designs, etc., all play positive roles [ 8 , 16 ]. Visual art (especially paintings) also plays an important role in medical space design and atmosphere creation [ 17 ]. In terms of decorations, the presence of artwork can enhance the overall satisfaction of patients through its impact on their mood, stress, comfort and expectations [ 18 ]. In addition, soothing music can reduce the stress associated with waiting and improve the overall waiting experience for patients [ 5 ].

• (4) Environmental Details

Relevant environmental details include windows and natural lighting and aspects of the physical indoor environment (indoor plants, light sources, sounds, odors, colors), which affect the perceptions of patients, staff and caregivers of the waiting room environment [ 19 ]. Windows and natural lighting: A sufficient number of windows is correlated with patient well-being [ 20 ]. Natural light and a quiet environment have a significant positive correlation with children’s satisfaction with space [ 21 ]. The degree of transparency of the indoor–outdoor boundary is significantly positively correlated with patients’ preferences [ 22 ]. The access of nursing staff to natural scenery and natural lighting may have a direct or indirect impact on the effectiveness of patient treatment [ 23 ]. Indoor physical environment: If real plants cannot be installed indoors, artificial plants can improve patients’ perceptions of the space [ 19 ]. Patients prefer warm artificial light sources [ 24 ]. In addition, high-intensity light can relieve patients’ depression [ 25 ]. The presence of either music or pleasant odors in the environment has been found to significantly reduce patients’ anxiety [ 26 ]. Safety, elegance, comfort, spaciousness, simplicity and brightness are the six factors affecting the perceived comfort of a room for mothers and infants. Users have been found to give higher comfort scores to rooms in warm colors such as orange or yellow [ 27 ].

1.2. Pediatric Waiting Rooms

In terms of architectural design, functionality and connectivity are the most important elements of the waiting space in pediatric clinics [ 8 ]. As noise made by children, such as crying, may affect other patients [ 28 ], it is vital to offer an appealing environment that holds the attention of child patients [ 29 ]. For example, the use of an interactive media display may improve the waiting experience for child patients and other visitors [ 30 ]. It has been reported that passive distraction can reduce patients’ anxiety and pain and reduce perceived waiting time [ 31 ]. In a study conducted at the Royal Children’s Hospital in Melbourne, environmental characteristics were found to enhance patients’ willingness to visit the hospital and even improve their health [ 32 ]. Exposure to nature, music and art, as well as uncrowded and peaceful environments, can enhance the pediatric healthcare building environment [ 33 ]. Meanwhile, teenage patients preferred bright colors [ 34 ] and emphasized their need for privacy in waiting rooms [ 35 ].

1.3. Research Question and Purpose

The literature [ 5 , 33 ] has demonstrated the effectiveness of evidence-based design as a scientific method of studying medical buildings. However, most recent research [ 17 , 19 , 36 ] has focused on emergency departments, nursing units, functional spaces and natural landscapes, rather than waiting spaces. There has been no clear account of specific factors in the pediatric waiting environment that can improve patients’ waiting experience and increase their satisfaction with the waiting process. Therefore, based on the method of evidence-based design, this study used a combination of subjective and objective methods to examine pediatric waiting spaces, collect users’ preferences and analyze the correlation between spatial elements and waiting satisfaction in pediatric clinics.

Based on evidence-based design theory, the key research question was as follows: What factors can make the pediatric waiting space environment more attractive to users? Based on the results of pre-investigation experiments, this key question was transformed into researchable questions via a dendritic structure. As a result, multiple questions emanated from one question, leading to four first-level indicators and twenty-seven second-level indicators as the evidence-based elements of this research ( Figure 1 ).

Evidence-based elements investigated in this study (source: self-drawn).

2.1. Observation

The research objects in this study were the pediatric waiting areas of three general hospitals in Shenzhen, China: The University of Hong Kong (HKU) Shenzhen Hospital, Shenzhen University (SZU) General Hospital and the Huazhong University of Science and Technology (HUST) Union Shenzhen Hospital ( Table 1 ).

Survey of the investigated hospitals (source: self-drawn).

This study observed the specific content of 27 elements in each of the three hospitals from 08:30 to 17:30 in November 2020, using the field survey template shown in Table 2 . The behavior patterns of the people waiting were also recorded.

Template for hospital field survey (source: authors).

2.2. Questionnaire

After the participants had signed an informed consent form, they completed a questionnaire evaluating their satisfaction with the waiting space and a questionnaire measuring their subjective preferences regarding the function layout, flowline organization, supporting facility and environmental details. Further explanations were offered to any participants who expressed uncertainty about one or more of the questions. In addition, interviews were carried out at the end of the survey process to ensure the validity of the research.

Satisfaction evaluation questionnaire: This questionnaire comprised 34 questions and had 3 sections: basic information, satisfaction evaluation and importance ranking. The basic information section comprised four questions collecting information on the age of the child patient, the age of the person/parent accompanying the child, the relationship between the child and their companion (e.g., parent–child) and the number of doctors involved in the child’s treatment. All of the data were kept anonymous. In the section on satisfaction, five levels (1 = lowest; 5 = highest), were used to evaluate the 27 indicators in Table 2 and overall satisfaction. In the importance ranking, respondents needed to rank four first-level indicators (function layout, flowline organization, supporting facility and environmental details) and 27 second-level indicators from the list provided

Subjective preference evaluation questionnaire: There were 30 questions in this questionnaire, including 27 preference choices (function layout, the width of the corridor and the material and color of the chairs, etc.) and 3 open questions regarding design suggestions for the waiting area.

3. Results and Discussion

3.1. functional layout.

• (1) Observation results

Layout of the waiting area: The survey at HKU Shenzhen Hospital ( Figure 2 ) revealed that the pediatric department has an outdoor landscaped garden, close to the semi-outdoor public corridor (point A in Figure 2 ). Such a landscape has a soothing effect on patients while also maximizing natural lighting and ventilation. However, according to on-site observations, the seating is positioned away from the garden (point B in Figure 2 ) and the window facing the back of the seating was not open at the time of the study, so the overall environment in the waiting area was humid and heavy ( Figure 3 ). Therefore, some people preferred to wait for their diagnostic results in semi-outdoor space C ( Figure 4 ).

Layout of waiting space ( A ) waiting space near the garden; ( B ) waiting space away from the garden; ( C ) waiting space next to the garden (source: self-drawn).

Waiting area B (source: self-photographed).

Non-waiting area C (source: self-photographed).

Inadequate divisions between waiting spaces: The survey in HUST revealed that four groups of families were required to gather at the entrance of the clinic. Unpredictable noise can be distracting for doctors, which may even trigger inaccurate diagnosis or medication advice (Ulrich et al., 2008). According to Hall’s theory of interpersonal communication distance, the social distance required by ordinary people is 1.22 m–3.66 m. The distance between waiting families in HUST was less than 1 m, intensifying the anxiety associated with receiving medical treatment. The solution offered by SZU General Hospital also failed to achieve the target effect due to mixed use of waiting spaces.

Waiting space occupied by strollers: All of the pediatric waiting areas were found to have problems with stroller obstruction. SZU General Hospital has the widest waiting corridor, at 3.5 m. However, when patients were seated on both sides, strollers still caused congestion in the corridor.

• (2) Subjective preference results

Waiting area and corridor width: In the survey, 30.8% of the respondents preferred a waiting area larger than 80 square meters, which was larger than the existing waiting spaces in the three hospitals. Layout of waiting area: 45.1% of the respondents preferred a combined hallway waiting space; only 11.3% of the respondents chose an enclosed inner hallway, which was the least popular option. Size of mother and infant room: The expected area of the mother and infant room was 6–20 square meters. Size of children’s play area: 16.9% of the respondents felt that there was no need for a play area, mainly because they were worried about “insecurity” and “physical discomfort”. However, 30.8% of the respondents thought that the children’s play area should be 21–30 square meters and that diversified play facilities should be provided.

3.2. Flow Organization

Crossflow: The pediatric department of the HUST Union Shenzhen Hospital was found to have a crossflow problem. The pediatric department is adjacent to the general hospital lobby, which provides seating in a rest area. As a result, the waiting room is divided into two areas and the entrance to the pediatric department is between the two areas. The flow of people about to enter the pediatric department crosses the flow of people returning to the lobby’s rest seats ( Figure 5 ). People gathering at the reception table also causes traffic congestion.

Area around reception table is crowded (source: self-drawn).

Waiting area too far from drinking water and bathroom facilities: There is a need for drinking water to make up milk for infants in a pediatric waiting area. At the HKU Shenzhen Hospital, the nearest drinking water and bathroom facilities are located 64 m away from the pediatric department. At the SZU General Hospital, the nearest drinking water and bathroom facilities are located in the pediatric department, parallel with the treatment rooms. However, to access these facilities, visitors have to travel 32 m along a narrow corridor with three turning points. The pediatric department at the HUST Union Shenzhen Hospital has two drinking water supplies, inside and outside the waiting area, which is very convenient. The nearest bathroom is also relatively close, at only 20 m away; it is accessed via a shared hallway with only two corners ( Figure 6 ).

Distance between waiting room and drinking water and bathroom facilities (source: self-drawn). ( a ) HKU Shenzhen Hospital; ( b ) SZU General Hospital; ( c ) HUST Union Shenzhen Hospital.

The number and distance of crossing points from the waiting area to the clinic: 43.6% of the respondents expected there to be only one crossing point; 29.2% expected there to be no crossing point. In addition, 87.7% of the respondents expected the distance from the waiting area to the consulting room to be less than 20 m. The respondents thus preferred to wait in a space with few turning points and facilities nearby. In terms of the distance from the waiting area to drinking water and bathroom facilities, 55.4% of the respondents expected these facilities to be less than 10 m away, while 41% preferred the distance between the waiting area and the toilet to be 11–20 m.

3.3. Supporting Facilities

Lack of child-friendly facilities: The pediatric waiting area of the HKU Shenzhen Hospital does not have special entertainment facilities (such as televisions) or toys for children. The HUST Union Shenzhen Hospital has TVs for entertainment and vertical electronic screens in the waiting space, but it also lacks children’s play facilities. The SZU General Hospital performs well in this regard. It has a dedicated children’s activity area, a large area of crawl mats for children and toys such as wooden horses.

Amount, location, combination and material of rest area seating: 54.4% of the respondents expected there to be more than 30 rest seats, 62.6% preferred a combination of multiple and single row seating, 40.5% preferred to sit near the window and 67.2% favored leather seats. Calling number display and informational signs: 52.3% of the respondents preferred multiple dispersed call numbering display screens. Regarding guide signs, 46.7% of the respondents preferred the wall-mounted type, while 37.4% chose the hanging type to avoid problems such as “obstruction of sight”.

3.4. Environmental Details

Lack of natural environment: At the HKU Shenzhen Hospital, the observation revealed a landscaped garden outside the waiting space, far away from the seating area. Distance from nature reduces its therapeutic effect. Some of the people waiting chose to wait near the garden, but this put them at risk of not hearing their names being called. In the HUST Union Shenzhen Hospital, the waiting space is enclosed by multiple walls and lacks natural scenery. The environment in the SZU General Hospital is the best, with large windows on the long side of the waiting space. There are no buildings outside the windows to block the line of sight. The view is wide and there is some natural scenery.

Inadequate child-friendly design: Some aspects of the design were found to fail to meet children’s usage requirements in the surveyed hospitals. The waiting areas have colorful cartoon decorations. Although the waiting area of the SZU General Hospital is equipped with child safe handrails, and its fire extinguisher facilities are equipped with anti-collision bars, the other two hospitals lack similar environmental considerations.

View outside the window: 22.1% of the respondents believed that a pediatric waiting area must offer a view out of a window, and 38.5% of the respondents believed that such a view may be necessary. Number of indoor green plants: 43.6% of the respondents expected there to be 3–5 indoor green plants. Warm and cold colors: 67.2% of the respondents preferred warm colors such as red, yellow and orange. Anti-slip surface: 64.1% of the waiting patients thought that an anti-slip surface is necessary. Sound, light and ventilation: 57.9% of the respondents preferred a quiet environment, 65.1% preferred a brightly lit environment and 64.6% preferred natural ventilation.

3.5. Analysis

• (1) Sample Validation and Reliability Analysis

A total of 240 questionnaire copies were distributed. HKU, SZU and HUST received 67, 74 and 68 valid questionnaires, with a recovery rate of 93%. To keep the same sample size, each hospital randomly selected 65 sample questionnaires by Excel for data analysis, and 195 questionnaires were selected for data analysis ( Table 3 ). Due to the limitations imposed by the children’s age on their cognitive abilities, the main questionnaires and interviews focused on the accompanying people/parents. Similar studies have focused on parents as the object of information collection (e.g., Cartland et al., 2018). In this study, children aged 3 and under accounted for 49.7% of the sample, children aged 4–6 accounted for 34.4% and preschool children were the main waiting population. The companions were mostly the children’s parents, of which fathers accounted for 41% and mothers accounted for 55.4%. The number of accompanying people ranged from 1 to 2, with an average of 1.6.

Questionnaire (source: authors).

The Cronbach’s alpha coefficients for the total data and the grouped data of the three hospitals were 0.948, 0.960, 0.937 and 0.946, respectively. As these values are all greater than 0.8, the questionnaire results were assumed to reflect the subjective satisfaction status of the waiting population.

• (2) Validity analysis and factor analysis

Kaiser–Meyer–Olkin (KMO) is a coefficient that reflects the validity of data, ranging from 0 to 1. A larger value indicates a higher correlation between variables, which is suitable for factor analysis. In general, the actual threshold is greater than 0.7. Validity analysis results showed that KMO was 0.914, greater than 0.7, indicating that the sample data were valid. Significance level was <0.001, indicating that the data is valid and suitable for factor analysis.

In the component matrix obtained by rotation, principal factors could generalize second-level indexes, and a correlation value that exceeds 0.5 is considered as a main factor. Thus, the 27 indicators are reduced to 6 main factors, which belong to 4 categories: (1). Functional layout: layout and area; (2) Flow organization; (3) Supporting facilities; and (4) Environmental details: physical environment and landscape environment.

Of the six main factors, the first factor related to supporting facilities. The second related to flow organization. The third and fourth factors can be summed up as functional layout and site area. The fifth factor related to light and dark, ventilation and acoustics, which can be summarized as the physical environment in the environmental details. The sixth factor was related to the landscape outside the window and the type(s) and quantity of indoor green plants. This factor can be summarized as landscape environment in the environmental details. Total analysis of variance revealed that the six factors had an explanatory ability of 69.762% ( Table 4 ). The selected factors showed a high level of representativeness and were able to explain users’ subjective satisfaction evaluation of the waiting space well.

Total Variance (source: self-drawn using SPSS).

Extraction Method: Principal Component Analysis.

• (3) Regression analysis

In regression analysis, it is assumed that the independent variable has no significant effect on the dependent variable, ANOVA is used to analyze whether the hypothesis is valid and less than 0.01 would overturn the hypothesis. Table 5 indicates that at least one of the six factors could have a significant impact on the satisfaction of waiting space.

ANOVA (source: self-drawn using SPSS).

a Dependent Variable: Overall satisfaction with waiting space. b Predictors:(Constant), Environmental details (physical environment), Supporting facilities, Environmental details (landscape environment), Functional layout (layout), Functional layout (area), Flow organization.

Regression analysis of the six factors showed that the overall regression effect was strong. The linear regression equation showed that the significance of the six factors was 0.000 (less than 0.05), indicating that all six factors had a significant positive correlation with the dependent variable ( Table 6 ). The results indicate that supporting facilities and environmental details (physical environment) have the closest relationship with satisfaction with the waiting space.

Coefficients for the factors influencing waiting space satisfaction a (source: self-drawn using SPSS).

a Dependent variable: overall satisfaction with the waiting space.

In general, satisfaction with environmental details (physical environment), supporting facilities and waiting space led to a higher satisfaction rate than the other factors. Environmental details (landscape environment), functional layout and the humanization of functional requirements also had an impact on satisfaction evaluation.

• (4) Satisfaction analysis

Spearman correlation analysis showed that all p values were 0.000, indicating that each index was correlated with satisfaction. As shown in Table 7 , all 27 second-level indicators are positively correlated with satisfaction.

Results of Spearman correlation analysis (Source: Self-drawn according to SPSS).

** indicates significance level p < 0.01, and correlation coefficient > 0.5 is displayed in bold.

Analysis of the average values of the first-level indicators (functional layout, flow organization, supporting facilities, environmental details) revealed similar levels of satisfaction with the waiting space at the HKU Shenzhen Hospital and the SZU General Hospital. At these hospitals, users’ satisfaction with the functional layout and environmental details was high, and the difference between the numerical values was less than 0.22. At HUST Union Shenzhen Hospital, users were more satisfied with the flow organization and supporting facilities, with the largest gap between the four numerical values being 0.35; satisfaction with environmental details was only 3.55, which is lower than the values for the other first-level indicators.

In the analysis of the average values of the secondary indicators ( Figure 7 ), satisfaction with indoor green plants (types and quantity) was low, indicating that the waiting areas fail to meet the human need for a view of nature. In addition, the size of children’s play areas should be increased.

Average values for secondary indicators at three hospitals. (source: self-drawn based on compiled data.)

The overall satisfaction value for the three hospitals was between 3.90 and 4.08 ( Figure 8 ). The satisfaction ratings for SZU General Hospital and HKU Shenzhen Hospital were 4.08 and 4.05, respectively, higher than the satisfaction rate for HUST Union Shenzhen Hospital (3.9).

Overall satisfaction with waiting at the three hospitals (source: self-drawn).

• (5) Importance Analysis

This study collected the subjective importance rankings of the questionnaire subjects for the four first-level indicators. The ranking by importance to the waiting population of the spatial elements was D—environmental details > B—flow organization > C—supporting facilities > A—functional layout ( Figure 9 ). In general, environmental details were the most important, flow organization and supporting facilities were the second most important and the functional layout was the least important. From the ranking of the importance of secondary indicators, it can be seen that the respondents emphasized objective elements of the waiting space that meet basic waiting needs ( Figure 10 ), such as a well-ventilated environment, call number display screens and guide signs. Factors such as the layout of the waiting space and distance from the clinic were also key elements.

Ranking by importance of the first-level indicators (source: self-drawn).

Ranking of the importance of secondary indicators (source: self-drawn).

4. Conclusions

Based on the basic process of evidence-based design, this study took pediatric waiting space as the research object and developed appropriate design strategies, based on extensive research, for four dimensions of waiting space: functional layout, flow organization, supporting facilities and environmental details.

There was a significant positive correlation between the functional layout of a pediatric waiting area and overall satisfaction with the waiting area. The waiting areas surveyed showed considerable differences in their size. The respondents preferred a larger space—larger than 80 square meters. The waiting area should be appropriately divided to give families a sense of privacy. The waiting people regarded layout as one of the most important factors in the waiting space. The waiting area should have a dedicated stroller parking area. It should be a combination of halls and corridors or an external corridor, and corridors should be between 3 m and 4.2 m wide. There was a positive correlation between the enclosure of the waiting space and satisfaction. Waiting people tended to prefer a semi-open and semi-private waiting space. In the current waiting areas, satisfaction with the size of mother and infant rooms and children’s play area was low. The respondents preferred mother and infant rooms to be 11–20 square meters and children’s play spaces to be 21–30 square meters.

• (2) Wayfinding

There was a positive correlation between the flow organization of a pediatric waiting area and overall satisfaction with the waiting area. The surveyed people awaiting diagnosis thought that the distance from the waiting area to the consulting room was one of the most important factors. It should be less than 20 m, with no more than one turning point. Currently, the waiting spaces are far away from drinking water and bathroom facilities. The respondents preferred to be less than 10 m away from drinking water facilities and less than 11–20 m away from bathrooms.

There was a significant positive correlation between the supporting facilities in the pediatric waiting areas and overall satisfaction with the waiting areas. The surveyed people awaiting diagnosis believe that the number of rest seats, the nature of the call number display and the form of the guide sign were important elements of the space. They preferred leather seats, proximity to windows, and multiple row and single row seating, and they thought that more than 30 seats should be available. Satisfaction with the existing table and chair materials was high. The respondents preferred call number display screens to be arranged in a dispersed manner. They favored wall-mounted guide signs, cartoon wall decorations, decentralized direct drinking water facilities and suspended TVs.

• (4) Environmental details

There was a significant positive correlation between the environmental details of the pediatric waiting areas and overall satisfaction with the waiting areas. According to principal factor analysis, the environment was divided into landscape environment and physical environment. The overall satisfaction level increased with the score for the physical environment.

In terms of landscape environment, the current waiting areas do not make full use of natural environmental resources and lack views of natural scenery outdoors. The surveyed people awaiting diagnosis preferred to see three to five indoor green plants, either hanging or in miniature beds. The color of the waiting space had a significant positive correlation with satisfaction. The respondents were satisfied with the current color environment. They preferred warm colors such as red, yellow and orange. An anti-skid surface was regarded as one of the most important elements of the waiting space. The respondents were highly satisfied with the clinics’ current anti-skid measures.

In terms of the physical environment, acoustics, light and ventilation all had significant positive correlations with overall satisfaction. A ventilated environment was regarded as one of the most important elements of waiting space. The respondents were satisfied with the existing lighting. They preferred an environment that is quiet, bright and naturally ventilated.

Limitations:

• (1) The COVID-19 pandemic posed several potential problems. The number of hospitals available for research was limited; the size and composition of the sample may not have been representative;
• (2) The research focused on large-scale general hospitals in Shenzhen. Therefore, the design strategies summarized here may not be generalizable. Future research should consider how to eliminate the influence of regional factors on the design of children’s waiting space.

Future research:

• (1) Although this study administered two questionnaires to a large number of participants, the conclusions drawn from the survey represent personal opinions, which require further validation. The findings of the survey should be compared with the opinions of expert practitioners and scholars to improve the scientific rationality and credibility of this paper.
• (2) Evidence-based design involves not only the initial search for evidence, analysis of evidence and extraction of evidence, but also the application of evidence in actual projects. The whole process, combining design with practice, eventually leads to a cyclic evidence-based design theory. However, this study did not explore the application of the proposed design strategy in practice. This strategy should be applied to design practice in the future to form a circular interactive relationship between evidence and practice.

Acknowledgments

We thank Qi Yi’s students, including Meng Zhou and Qiong Zhou, for providing help during the investigation. This study was conducted as part of a master’s thesis in evidence-based design for pediatrics waiting space.

Author Contributions

Conceptualization, Y.Q. and Y.Y.; methodology, S.S.L.; software, Y.Y.; validation, Y.Y.; formal analysis, Y.T.; investigation, Y.Y.; resources, Y.Q.; data curation, Y.Q. and Y.Y.; writing—original draft preparation, Y.Q. and Y.Y.; writing—review and editing, S.S.L. and Y.T.; visualization, Y.T.; supervision, S.S.L.; project administration, Y.Q. and Y.T.; funding acquisition, Y.Q. and Y.T. All authors have read and agreed to the published version of the manuscript.

This research was funded by National Natural Science Foundation of China, grant number 51908360 and 52108018, Industry-Academy Cooperative Education Project from Ministry of Education, grant number 202101126047, Shenzhen Science and Technology Innovation Committee, grant number 20200814153705001, and Natural Science Foundation of SZU, grant number QNJS0196.

Institutional Review Board Statement

Ethical review and approval were waived for this study by the university, for the reasoning that the study was targeted at the impression of the space, without involving the further personal information of the respondents.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Breaking News

Social conformity & groupthink.

Groupthink: A cultural phenomenon where group-self-reflection is discouraged to preserve group identity and unity.

A mythical experiment is often used to illustrate groupthink – 5 hungry monkeys in a cage attack any monkey in the cage who tries to grab a banana – an experimental punishment dished out to the whole group when the bananas are touched.

The video below shows a modern twist on this experiment – a patient in a waiting room is influenced to stand up on hearing a beep because others are doing it. She then perpetuates this phenomenon to others.

Overcoming groupthink is extremely difficult and can take an embarrassingly long time – particularly in an authoritative top down command structure.

Practices maintained through command structures often go unchallenged through fear . They can be perpetuated and reinforced for years – read an amusing example here – signing a bicycle register at one hospital for those who rode to work. The register originated in the days of rationing during WWII and was of no relevance for the next 60 years – however it persisted.

Perhaps the #TheatreCapChallenge demonstrates the sheer grip of groupthink and social conformity. Within a command structure staff feel threatened doing anything which is not dictated from the top down. These threats aren’t only imagined – they’re real. We all have mouths to feed and most of us have mortgages to pay – are we going to risk it?

In most instances it appears not – a real shame given we work in a high risk industry – in not changing we won’t improve and patients lives are left at unnecessary risk.

Failure to adopt the #TheatreCapChallenge perhaps illustrates the negative grip of groupthink in healthcare.

The initiative has overwhelming support from patients

and front line staff alike:

However despite this support it hasn’t (yet) been readily adopted.

Support for the initiative is heavily skewed – those who’ve been in healthcare the longest, with perhaps the greatest influence in a command structure, are the least supportive.

These are the results for the same question above when filtered out to surgeons who have worked in healthcare for more than 20 years:

This phenomenon is understandable – perhaps it’s more upsetting for them to acknowledge they could have been doing a better job all this time through a simple intervention. Perhaps they may never accept it such is the power of cognitive dissonance .

Compare the above results with those from nursing & medical students:

Change and improvement is easily stifled by the influential few in a command structure – unfortunately it is our patients and front line staff who suffer.

Things aren’t all bad. To reach a tipping point, and see a change occur universally one only requires the initiative to be adopted by 25% ( see here ). However anything less and the initiative will fail. There are a few useful tools to help reach the 25% milestone and we’ve witnessed them playing out on social media – NHS trusts competing against one another to see who has the most staff wearing name & role hats (great to see the NHS leading the way on their 70th birthday). This map clearly demonstrates the impact this friendly competition has had:

Get 25% of your theatre staff wearing name and role theatre hats and the change is on. Perhaps a great day to focus on making this happen – 23rd July – international #hellomynameis day.

While authoritative command structures readily stifle change they are extremely useful for delivering other things and have demonstrated this for centuries. Increasing efficiency in simple systems, problem solving, education, disciplining……

However, except for rare instances ( see here ) they struggle to deliver the improvements required to make our front line environments simpler and safer to interface with for patient safety.

For these patient safety interventions to be delivered we would be better served by transparent networked frameworks – a Team of Teams – which more readily seek and develop solutions in complex environments. These structures are leadership driven – where anyone with a passion to drive improvement can help in delivering it.

For a Team of Teams to flourish those in managerial positions need to transition from being the voice of authority and instead act as facilitators of front line driven initiatives.

For patient safety to improve healthcare needs to utilise Command and Team of Teams frameworks in harmony with one another.

For this to happen, to break free of the group think, perhaps we’ll need to get our thinking caps on.

Interestingly interventions which make our work environments more complex may be more readily supported as they provide our peers with a competitive edge ( after 15 years of data and 4000 studies there is insufficient evidence of patient benefit in using surgical robots which cost millions. However in some environments they’ve been more readily adopted than name & role hats which are essentially free and obviously improve communication and teamwork for patient benefit). A hospital may promote its reputation through having a robot – lay people incorrectly perceiving it represents a modern forward thinking institution.

For patient safety to improve we need a hospitals reputation to be based on providing the optimal environment for patient care – as judged by those best understand it – primarily front line staff. The NHS is leading the way through a subjective leaderboard which scores hospitals based amongst other things upon ‘the percentage of staff who feel able to contribute towards improvements at their trust’ ( see here ) perhaps we can make this league table more objective.

While we train our medical and nursing staff to be as good as they can possibly be if we continue to make the environment they work in increasingly complex then we will increasingly fail.

It’s time for change.

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The Narkomfin Building in Moscow (1928-29): a Built Experiment on Everyday Life

December 4, 2016 by Fosco Lucarelli 2 Comments

The Narkomfin Building (Dom Narkomfin) in Moscow was designed by Moisei Ginzburg and Ignatii Milinis in 1928 to host collective housing for employees of the  Narodnyo Kommissariat Finansov (the People’s Commissariat of Finance).

Completed in 1932, the Narkomfin is one of the few actually built architectural works responding to the constructivist aim of reinventing the everyday life of people, ( byt in Russian), trough typologically experimental buildings that embodied new Socialist ideals.

The main principle behind the conception of the building is the collectivization of all the areas that corresponded to collective functions. Reading, cooking, raising children, doing sport, all are functions conceptually removed from the traditional -bourgeois- apartment, and relocated within a  glazed, collective volume hosting communal kindergartens, kitchens, libraries and gymnasiums. The upper roof would also work as a communal recreative space.

The individual spaces, eg. rooms for sleeping, washrooms and toilets, as well as study and individual research areas are, instead, hosted in a long block with ribbon windows. The windows, here, open widely towards the exterior natural setting, implicitly questioning the closed and interior nature of a “room”.

The two six-storey-high compounds, one destined to individual activities and the other to collective ones, are connected by a covered bridge and an exterior communal garden.

The duplex flats were divided into two types, the K Types which still included a surface for children and cooking, and the F Types, where all the communal functions, located outside of the apartments, implied that all children should be raised collectively in order to contrast patriarchial relationships. The transformation of cooking into a communal activity would also allow women to be freed from household responsibilities and question the privatization of couple relationships.

After Stalin’s rise to power, the Narkomfin’s communal spaces fell in abandon and kitchens were added by the inhabitants to the single apartments.

In his blog Charnel House , Ross Wolfe collected several beautiful pictures of the buildings by different photographers:

1. Charles Dedoyard, a Frenchman and contributor to the avantgarde magazine L’Architecture d’aujourd’hui; 2. Vladimir Gruntal, a noted constructivist photographer and member  of Rodchenko’s October Association; and 3. Robert Byron, a British travel writer and Byzantine historian known  for his deep appreciation of architecture.

Further reading and more photographs:

Dom Narkomfin in Moscow, 1929, Moisei Ginzburg & Ignatii Milinis’ iconic constructivist masterpiece , in: Charnel House.

Moisei Ginzburg’s constructivist masterpiece: Narkomfin during the 1930s , in Charnel House

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October 18, 2018 at 3:26 pm

Hi , I am writing a dissertation on communal living and why we should build schemes like Dom Narkomfin again. I was wondering if you have any recommendations for reading material on the constructivist idea of revolutionizing the every day life . I would be very grateful if you could recommend me any other similar projects .

April 30, 2020 at 1:48 pm

Hi Paula, its probably too late for you, but if someone else might search for something similar, the book “Dwelling” by Moisei Ginzburg was recently translated into English and could be very helpful for research.

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Can light-based art improve your health? This Philly exhibition wants to find out

The jefferson university center for immersive arts for health is using a gallery exhibition to experiment with ways art can improve medical appointments..

• Peter Crimmins

Lyn Godley's ''Light Ripple'' is a centerpiece of Waiting Room, an exhibit at Hot Bed gallery based on the idea that immersive art can improve health outcomes. (Emma Lee/WHYY)

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Other pieces include ”Installation” by Jessica Judith Beckwith, which features a room full of pieces of plexiglass shaped into curved sculptures dangling from the ceiling, creating abstract shadow plays of reflected light and shadow on the walls. Philip Hart contributed several mobiles, both desktop and suspended, whose metallic surfaces react to subtle air currents in the room and reflect light onto the walls.

None of the pieces in “Waiting Room” are labeled with wall text; the gallery provides a printed list (with prices) on request. However each piece is accompanied by a QR code on the wall.

This is where the exhibition turns into an experiment: When activated by a cell phone, the code takes viewers to an online survey, asking questions such has how the viewer felt while looking at the piece, how much time they spent looking at it, and if they would like to see it in a doctor’s waiting room.

Godley said “Waiting Room” is about collecting data from viewers.

“We’re actually getting feedback, and we’re hoping feedback leads to further research,” said Godley. “It is difficult going after medical research grants where you’re going up against heavy cancer research and say, ‘Well, we think art could help.’ Or having people who are reading those grants understand that when we talk about using light, we’re not talking about just lighting the room.”

Since “Waiting Room” opened in September, Godley said the feedback she has received has been what she hoped it would be, with viewers describing the pieces with words like “peaceful,” “calm,” and “less stressed.”

However, one piece is an outlier: Fowler’s “Star Tunnel.” Viewers do not find it relaxing.

“The words that are coming up for that are panic, stressed out, anxiety,” said Godley.

Those negative reactions may be more scientifically enlightening than the positive.

“You need something that says, ‘No, something doesn’t work,’ for us to start to understand why these things are working,” she said. “That’s been good. I don’t think that the artist thinks that’s good, but, you know, that’s OK.”

“Waiting Room” will be on view at Hot•Bed until Nov. 19.

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Why My Patients Sit Where They Sit Save

• Jack Cush, MD

I used to do this bit where I would open a lecture with a psychoanalytic profile based on how one eats an Oreo. While more entertaining than fact, the way you eat the Oreo probably says something about your personality.

There are whole biters, nibblers, dunkers, twist/lick/tossers, and the curious wafer-only eaters. The purpose of the bit was to make you think about yourself (and others). 

But what do you think about where your patients sit?  You may have never considered this or noticed what's going one? I have, and I've struggled to understand the psychology that drives patient choice of seating.

This discussion is all based on my curious observation that when I enter the exam room, I usually find the patient sitting in the wrong chair.  Meaning, he/she is not seated where I would expect the patient to sit in a medical visit.

I’ll accept that where a patient sits may differ between physicians, practices types, seating quality and patient comfort. I’ll also accept this may be a figment of my keen observational skills. Nonetheless, errant sitting occurs in both the new and experienced patient medical visits, and accounts for at least 12 seconds of quality time 10-20 times a day.  

My unofficial statistics on seating behavior shows that 55% of patients sit in the chair furthest from the doctor.  This is what has me unglued. Is this a psychologic or feng shui issue?  The remaining 25% are on the exam table and 20% will (correctly) sit next to the doctor's desk and computer. 

Where you sit has been been the subject of psychologic analyses, and there are several treatises on the subject. This issue comes up in situations beyond the exam room: classrooms, interviews, business meetings, the dinner table, etc.  Each says something about the sitter.  Is he/she collaborative or confrontational, engaging or withdrawn, confident or curious, uncomfortable or tired?

This is what I can surmise from my quick study of the issue. There are four places one can sit in my exam room.  

The Physician's Rolling Stool Who sits here : four-year-olds, physicians and the socially inappropriate rule breakers (hopefully there is no overlap in these 3 possibilities). Interpretation : Stools are meant to be mobile and space economic. It is not a natural choice, especially for those with arthritis or pain. Children I can understand; the stool has a pneumatic lever and it doubles as a time-waster toy until the damage is done. The socially inappropriate adult sits here as a show of dominance, authority and a desire to be the center of attention. After all, performers and storytellers love to sit on stools.  And then there's the doctor (for all the aforementioned reasons).

The Exam Table Who sits here : Sick people, rule followers, and sleepy heads. Interpretation :  I perform my history and the exam with the patient seated in a chair. The table is occasionally used for abdominal, neurologic or exams of those who are frail or obviously ill. Hence, for the remaining 95% of patients, finding someone who voluntarily sits on the table is unnerving.  Of course, there are the rule-follower patients who have been taught to sit on the table in other offices, like the gynecologist. Sleepy heads are either insomniacs who treasure any recumbent space or the ones smart enough to fill the doctor wait with a refreshing, power nap.

The Chair Furthest (from the Doctor's Desk) Who sits here : Most new patients, many follow-up patients, and those who would rather be in the dentist chair or waiting room (instead of this exam room).  Interpretation :  It's actually hard to discern why a patient starts out with the most possible space between you and them.  Is it natural or are they subliminally worried, cautious, wary, defensive, competitive, judgemental or aloof?  Migration to this chair is likely some form of self preservation. It could also be that exam rooms with a desk and a computer are viewed as where the devil's work occurs. The desk may be a threatening, territorial divide or communication barrier. Patients need to be taught how and why (if) you use a desk and computer.

The Chair Next to Doctor's Desk Who sits there : Happy collaborative types, the unafraid, and the well trained Interpretation : Psychologists say that those who sit next to you (parallel or cornered) tend to be causal, positive, friendly, collaborative.  For many, it's not till the fourth or fifth date (visit) that they will assume the safe position you prefer. Until then you just have to wonder why.

Finally, I'm working on this formula wherein the distance between me and the patient, divided by the number chair/seating options equals my Q rating (likeability score).  Maybe I can get OMERACT to study this.

Where do your patients sit? I'd love to hear your thoughts and observations.

Next week we’ll talk about the patient hand shake - creepy or great?

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Home > Watson Life Resources > Behavior > Mini-Schedule and Behavior Story: Doctor Appointment

© Copyright 2024 Watson Institute. The Watson Institute (Watson) encourages you to access and print material from our website at www.thewatsoninstitute.org for personal use only. Any other copying, linking to another website, blog post or social media, distribution, modification, transmission, or dissemination of the website content is strictly prohibited without the prior written permission of Watson. View full terms of use.

Mini-Schedule and Behavior Story: Doctor Appointment

My friend’s daughter is 5 and was diagnosed with autism around age 2. She has trouble in public places. I am wondering if anything can help with her aggressive behavior at the doctor. A lot of the employees there have been pinched or bitten by her. Is there something that will help her feel more comfortable in public and with doctors?

Doctor appointments can be a stressful time for children.  Since some children with Autism have difficulty communicating emotions, consequently we often see behavioral issues. Try using behavioral stories to prepare her for the doctor appointment, and a mini-schedule when at the doctor office. These suggestions may help with reducing anxiety and prevent behavioral issues associated with the doctor appointment.

A Behavior story is a simple description of a social situation, written from a child’s perspective. The situation is described in detail and focuses on the important social cues, events, expectations and ways for the child to react in the situation. Behavior stories are intended to be used with a child prior to an event. It is rehearsed with an adult so that when the event actually occurs, the child can use the story as a guide for behavior. A Mini Schedule provides the child a visual support outlining steps of an event.  It can be in picture, object, word or numeral format. A mini-schedule can give a sense of time and when an activity will end.  Children often like to check off each item as it occurs. Knowing what and when things happen can help reduce anxiety and prevent many behavioral issues. You can draw the pictures, write the words if the child reads, use pictures from the internet, Boardmaker visuals, or use objects. As you do each activity cross it off so the child can see what is next and when she is finished.

Quick Facts

• Child's Age: 3-5, 6-10, 11-13, 14-17, 18+
• Planning Effort: Moderate
• Difficulty Level: Moderate

Pre-requisites

Child must be able to understand simple stories, words or what pictures represent.

Create a simple story that includes the behavior(s) of concern, and how the behavior may make others feel. Include what the child can do instead of the concerning behavior(s).  Incorporate the child’s special interest or favorite cartoon character.  If possible add pictures of the child, pictures of the doctor’s office, exam room, and staff that will come in contact with the child. Below is an example of a behavior story for going to the doctor. Add to it and adapt to her needs. Read the Behavior Story with her frequently, prior to the appointment. Think about exactly what will take place at the doctor appointment. Create a few visuals outlining the appointment (sitting in waiting room, getting weighed and measured, talking with nurse, having temperature taken) If possible put something preferred at the end of the mini schedule such as going for ice-cream or getting a sticker. Have the child cross off or you can cross off each item when the item is completed. Be consistent with schedule. You may want to consider taking your child to the office once or twice to get a sticker/treat from receptionist/nurse prior to your visit. This will help your child see the environment in a more positive way.  Most Dr. offices would be willing to cooperate with some advance notice.

Documents and Related Resources

Mini-Schedule for Public Settings   do2learn  (website for picture cards)   Indiana University  (website for using visual schedules)   Going to the Doctor Behavior Story  (Word document)

If you have questions or concerns about the Watson Institute’s use of this information, please contact us .

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Annual Review of Sociology

Volume 43, 2017, review article, field experiments across the social sciences.

• Delia Baldassarri 1 , and Maria Abascal 2
• View Affiliations Hide Affiliations Affiliations: 1 Department of Sociology, New York University, New York, New York 10012; email: [email protected] 2 Department of Sociology, Columbia University, New York, New York 10027; email: [email protected]
• Vol. 43:41-73 (Volume publication date July 2017) https://doi.org/10.1146/annurev-soc-073014-112445
• First published as a Review in Advance on May 22, 2017
• © Annual Reviews

Using field experiments, scholars can identify causal effects via randomization while studying people and groups in their naturally occurring contexts. In light of renewed interest in field experimental methods, this review covers a wide range of field experiments from across the social sciences, with an eye to those that adopt virtuous practices, including unobtrusive measurement, naturalistic interventions, attention to realistic outcomes and consequential behaviors, and application to diverse samples and settings. The review covers four broad research areas of substantive and policy interest: first, randomized controlled trials, with a focus on policy interventions in economic development, poverty reduction, and education; second, experiments on the role that norms, motivations, and incentives play in shaping behavior; third, experiments on political mobilization, social influence, and institutional effects; and fourth, experiments on prejudice and discrimination. We discuss methodological issues concerning generalizability and scalability as well as ethical issues related to field experimental methods. We conclude by arguing that field experiments are well equipped to advance the kind of middle-range theorizing that sociologists value.

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