“Designing for Health" is a monthly, Web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments. This month's article focuses on safety in behavioral health facilities.

Mental disorders are more common than you may think. According to the National Institute for Mental Health, more than one-quarter of all Americans over the age of 18 suffer from a diagnosable mental disorder every year.(1) Six percent suffer from the most serious disorders(2)—those which often require hospitalization.

Diagnosing and treating these conditions require healthy, healing environments, yet our existing building stock is not up to the task. Conventional perceptions of psychiatric hospitals conjure up imagery of massive, gothic institutions from the early 20th century. This was the State Hospital—the first model for psychiatric care. That model began to shift in the mid 20th century toward smaller, community-based hospitals. Yet the heavy, institutional character survived. Thick walls, few windows, heavy doors, and an oppressive atmosphere still endure. Visually, they are a sibling to jails or other correctional facilities.

Patients and staff want a healthier environment than these existing buildings afford—one that is lighter, brighter, more compassionate and more human. An incredible design opportunity awaits. However, all these goals must balance against one critical consideration: safety. The safety of patients and staff is cited as the number one concern in the design of behavioral health facilities.(3)

Traditionally, safety has been resolved by designers using a correctional system approach: Contain the patient. Remove items that may be used as weapons. And build it strong. It has been used to excuse an institutional character. But rather than allow safety to diminish the quality of a space, we have an opportunity to craft sensitive spaces that use safety to positively inform the design and support patient outcomes. To achieve this, we need to understand safety from a holistic sense. What type of patient population is using the space? What are the functional requirements of the treatment program? What at-risk events is the owner trying to control? The design team must advocate a process to engage the user group and understand the unique requirements for a behavioral health project.

Safety is achieved at all levels of design, from a global perspective to finer levels of detail. If designed well, a space can be safe and provide other qualitative benefits for occupants. Safety begins at the perimeter of a building or unit. In many cases a nurse station will serve as a control point for access or egress. Traditionally, staff are stationed behind protective walls and windows, physically isolated from the patients. However, this approach can create an “us” versus “them” environment that may undermine the effectiveness of treatment programs.

This was one legacy at Adventist Behavioral Health, a behavioral health facility located in Rockville, Maryland. In November of 2009, the hospital completed renovations to a 27-bed unit for adolescent girls, which stands as a model for rethinking how we achieve safety and how the physical environment supports treatment programs.

From the onset, the owner identified the existing nurse station as an impediment to facilitating a healthy environment. “It was put there for the safety of staff, but it can create a hostile environment that says ‘you are scary. We need to separate ourselves because you might hurt us’,” says program director Simone Bramble, MSW, LSCW-C. “It was not therapeutic. Instead, we want to encourage spending time with the kids to minimize those relationship fractures when you create such an environment.”

The design solution eliminated these physical and psychological barriers. The nurse station was “opened” and treated as a sculptural element within the traditional patient area. Separate spaces became one, replacing a confrontational environment with one that encourages patient and staff interaction.

“It was important for us to create an environment that gives residents and their families hope," says Sako Maki, president of Adventist Behavioral Health. “Our design team helped us achieve this by incorporating natural light into the residential treatment center, creating softer architectural lines such as archways that lead to larger group therapy areas, and a modern, centrally located nurse station that allows for more resident and staff interaction. These changes helped us provide better care by creating a welcoming environment that is more conducive to successful behavioral therapy.”

Safety is also achieved via visibility. Empirical evidence suggests patients are most prone to harm themselves when they are alone. Visibility is achieved in two ways. First, the unit should be organized such that obscured areas are eliminated. Interior glazing can provide a visual connection to adjoining spaces, such as a corridor, which will serve as a psychological impediment to at-risk behavior. A visual connection always must be maintained between staff and patients. This requires careful evaluation of sightlines in plan and elevation. The less compartmentalized the plan, the easier this is to achieve.

Second, visibility is facilitated through thoughtful provision of light. Lighting is most successful when artificial sources are balanced with natural light. Daylighitng has been shown to support our circadian rhythms and physical and emotional well-being, and exterior glazing may offer a positive distraction with views to nature. Minimum light levels allow staff to see all areas and are a disincentive to at-risk behavior. But they may also be manipulated, by providing increased light levels in areas that may be perceived as trouble spots, such as toilet rooms, laundry rooms, or other less public areas. The perception of a space can modify behavior.

Safety is also realized by removing any materials, products, or assemblies that may be used as a weapon. They must be durable and of sound construction. This will govern the detailing of millwork assemblies, specification of plumbing/mechanical/electrical fixtures, and selection of hardware and furniture. Historically, designers have been very limited in the range of products available, often looking to the correctional industry for products. But in recent years, manufacturers have broadened their offerings and offered levels of customization previously unseen. This affords the opportunity for a more tailored design to the client’s needs.

The success of these selections will require special attention by the design team. The design process will require greater engagement with the owner and less assumptions than other project typologies may allow. Conventional construction methods and details will not suffice without some adjustment. Custom detailing and specifications are required for behavioral health projects. As the design team selects materials, samples should be provided to the owner for field testing.

Only in a healthy environment can behavioral health treatment programs thrive. Safety can complement, rather than impede, spaces that are warm, bright, and sensitive to occupants’ needs.

Click here for a chart of a survey using PACI Method, developed by Dr. Christine Timko. Research and chart by Jamie Huffcut, LEED AP, Marymount University.

Jordan Thompson, AIA, NCARB, LEED AP, is a project architect with the Washington, D.C. office of Perkins+Will. He can be reached at jordan.thompson@perkinswill.com.

 

1  http://www.nimh.nih.gov/health/topics/statistics/index.shtml. December 2, 2009.

2  Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun; 62(6):617-27.   

3  “Implementation of Evidence Based Design in Adolescent Behavioral Health Facilities.” Jamie Huffcut, Marymount University, Spring 2008. Survey based upon PACI methodology developed by Dr. Christine Timko, Stanford University, 1996.

Past installments of "Designing for Health" include (click on title to access the full article):
• A Harmonious Companionship-- Rejuvenating State-of-the-Art
• Leading by Design – A Place to Flourish
• Expanding the Definition of Sustainability to Include Chemical Awareness
• 10 Strategies to Move Your Client Toward Sustainability
• The Age Factor--Energizing the Healthcare Workplace
• Medical Teaming Centers
• Integrating Security in Hospital Emergency Departments
• We Eat What We Build
• Evidence-Based Healthcare Design Forum