Version:1.0StartHTML:0000000167EndHTML:0000031665StartFragment:0000000457EndFragment:0000031649 Themental health care system has flaws. The flaws faced, stem fromhistorical stigmas and modern criticisms and interpretations, such asthe ideas of what mental illness actually is.
The improper followthrough with programs and outdated facilities adds to the fear ofpatients in the outside world. One step to fixing these problems isstarting with the basics. As designers one of the thing we can do isgive patients a facility that is conducive to their healing process.
Mentalhealth is defined as a person’s condition with regard to theirpsychological and emotional well-being, many people use thisinterchangeably with behavioral health(1). Behavioral Health isdefined as any change in behavior that can effect ones health.Examples of behavioral health can include but are not limited tosubstance abuse, bipolar, anxiety and others that can fall undermental health.
In essence behavioral health is an umbrella thatcovers not only mental health but genetic problems and also healthyliving.(2) Adolescents can have serious mental health issues thatcan hit them at anytime. Many are already so lost and confused withwho they are and how they are supposed to act, that sometimes amental health problem can go untreated for years. The reasoning forthis is best summed up in the definition of the adolescent, “theambiguity of the phase between childhood and adulthood thatchallenges the adolescent to define themselves while society placesthem, changes in identity, biological development and peerinteraction result in behaviors mistrusted by adults”. Whenthinking of a Behavioral Healthcare Facility, most people’s mind willimmediately jump to horror stories they have heard. Some parts ofhistory would prove them right, however, it is important to look backto see how far treatment has come in a relativley short time span. Inancient cultures it was popular belief that “madness” was causedby evil spirits and divine punishment,(Malcolm, 2016) The ancientGreeks associated mental illness with physical illness and inmedieval times the belief was that saints, martyrs and relics werethe only things that could cure the followers of jesus.
(Malcolm,2016) During the age of enlightenment, doctors admitted that someforms of madness belonged to the divine, but others belonged toscience; however, the problem with this was that no one knew wherethe line was drawn.(Malcolm, 2016) The 18th century brought about thegeneral conclusion that mental illness was rooted in the generalstudy of illness.(Malcolm, 2016) About a hundred years later thefirst Insane Asylum was erected with the thought that changing theenvironment the patients are immersed in, to a more forgiving place,could help restore their sanity.(Malcolm, 2016) However, with thissafe environment came experimental techniques to restore sanityfaster. These techniques included near death experiences consistingof putting patients in cages and submerging them completely intowater until they stopped breathing at which point they would beyanked out.(Malcolm, 2016) It was also believed that patients couldbe “shocked” to sane by tying them to chairs and spinning themuntil they puked and emptied their bowels.
(Malcolm, 2016) Anothermethod consisted of the “tranquilizer”, whichwas a restraining chair that had padding that went over the eyes andears, essentially cutting off all senses and reducing blood flow.(Malcolm, 2016) At which point cold water was poured on the head ofthe patient and hot water was poured on the feet in order to “drawthe insanity out”.(Malcolm, 2016) In the 20th century following thethought the mental illness derived from a psychological problem,lobotomies and electroshock therapy was made possible and implementedon patients.(Malcolm, 2016) This was because the general consensusthroughout society was that the mad were seen as the walking dead andthey had lost all their human rights(Malcolm, 2016). While most wouldsay that the patients are being treated better than in the past,there are still modern day horror stories.
In2014, a hospital in Guatemala was called “the worlds most dangeroushospital”, according to Chris Rogers. On his trip there he had seenpatients left out to burn in the sun while heavily sedated, dressedin rags with shaved heads(Rogers, 2014). Some were completely nakedcovered in feces and urine(Rogers, 2014).
While touring through thehospital, patients begged him to take them out of the hospital andothers reported being raped by staff, either while sedated, sleepingor wide awake(Rogers, 2014). While being secretly filmed, thedirector of the hospital admits that patients are being raped by themale staff(Rogers, 2014). When Rogers asked about staffing, he wastold that two or three nurses are left to look after 60 to 70patients(Rogers, 2014). The Guatemalan government’s response to theinvestigation was that they follow all of the rules set forth byWorld Health Organization(Rogers, 2014). A legal case was broughtforward in 2015, but no account of what happened can be found(Rogers,2014).Itcame to light in July of 2016 that in the 60’s and 70’s a doctornamed Kenneth Milner was using truth serum on hispatients(Kemp,2016). This took place at Ashton Hall Hospital inDerbyshire, and was brought to light by the posting of pictures ofthe old hospital before its demolition(Kemp,2016). Former patientsstarted telling of their experiences and unanswered questions theyhad about their treatments(Kemp,2016).
One patient had mentioned thatshe was told to strip for an internal examination and then asked aseries of questions while the serum was administered(Kemp,2016). 60years after the fact an investigation is being launched into a manwho has been dead for almost 25 years(Kemp,2016). Withthe more research conducted one just finds more areas to place blame.For instance, there are five very different stories from the familymembers of patients who ended up dying after leaving a facility. Onestory tells of a mother who lost her insurance and had to pay over$40,000 in bills for her daughter’s mental health treatment. Afterwatching her mother stress about payments and feeling all of theguilt, the daughter had killed herself (Spencer,2014). Another tellsof a girl who died at the age of 14, after being told she would haveto stay at a facility for 12 weeks.
When the girl had reached a”healthy” weight, the insurance company stopped paying at sixweeks and the girl had to go home even though she was not mentallyready. Two days after being home and purging she had died from heartfailure(Pelley,2014). The fact is that even though there are laws andorganizations in place to better the care of mental patients themental health system is still broken.
As the practices of psychiatryhave been forced to change in the face of low health insurancereimbursements, hospital bed have been disappearing.(Abbott, 2004)When looking at facilities most of the time the blame can not be putsolely on one area. A facility has to not only have a staff that iswell equiped but a building that can accommodate the needs of thepatients. Accordingto the W.H.O depression is predicted to be the second leading globalburden disease by 2020(Gender differences). Many people are afraid tocome forward and admit that their is something wrong because of thestigmas set by society. In 2006 an Australian study found that one infour people thought depression was a sign of weakness and that 42%thought people with depression were unpredictable.
(4) Many ofthese stigmas can be found in the media which is just spreading themisconceptions instead of fighting them.(5) The media should betelling facts like depression is reported to be twice as common inwomen than men across diverse societies and social contexts(Gendderdifferences). More than 350 million people of all ages havedepression and there are interrelationships between depression andphysical health.(7) Some other health conditions and life stylefactors associated with depression include obesity, hypertension, andsmoking.(gender differences) There are certain signs that will helpsomeone tell if a person may be depressed.
Some signs includesignificant weight loss or gain, lack of interest in things they usedto enjoy, insomnia or excessive sleeping, highs and lows in emotionsand the inability to concentrate.(9) There are many steps to take ifone might have depression and depending on the severity of theproblem, it may be suggested by a professional that someone should goto a behavioral health care facility. When someone is first admittedthey have a Patient suicide risk assessment done; however, the toolscurrently available for this are unreliable(Hunt,2015). With this inmind, designers and architects should proceed as if there is no wayof knowing a patients true intentions(inser). Thefirst step in trying to figure out how to build a Behavioral healthcare facility is to make sure you’re aware of the differences betweenpsychiatric hospitals when compared to medical hospitals. While inmedical hospitals, patient treatment takes place in patient rooms; inpsychiatric treatment centers patients are encouraged to leave theirroom and join group therapy and spend time in social areas.
Familyvisitation, while strict at a medical hospital, is more encouraged ata behavioral healthcare facility and it is preferred that they meetin semi public areas. Other differences include, infection control,where isolation is rarely used in behavioral facilities because ofthe nomadic nature of the patient population. Avaluable way of figuring out how to build facilities that work is bylooking at ones that don’t and figure out why. Some of the reasonsfor facilities not working consist of problematic design,technological failure and evolution. Problematic design comes fromthe fact that many architectural design awards are based on the waythey look and not how they function in context.(Sine, 2009) Oftentimes when a facility, is built the form is forever playing catch upwith the technological advancements and treatment theories that areconstantly changing.
(Sine, 2009) Along with the change in theoriesand the way of clinicians’ thinking, building and health codes arechanging while the building of new facilities are happening(Sine,2009). While all this is happening, the buildings themselves need tobe more adaptable to all the changes. For all of these reasons, manyof the existing facilities have become too costly to maintain, arenot energy efficient, technologically outdated, and do not provide anenvironment that can keep pace with the current standard of care fora safe environment. (Sine, 2009) With older facilities, theinstitutional environments did not offer enough flexibility foradapting spaces to patient demographics (deinstitutionalizingdesign). Afterlooking at what does not work, one should look at facilities that do.Two example of facilities that work are Brentwood Meadow, andSheppard Pratt’s. Brentwood Meadow is in the tri-state area ofIndiana, Kentucky, and Illinois. This facility utilizes both indoorand outdoor spaces for recovery(Hammer, 2010).
The exterior is a mixof stone and brick work to make the facade look moreresidential(Hammer, 2010). The outdoor amenities contain threeseparate veranda style courtyards that include a patio, rockingchairs, ceiling fans, and a fenced in area for privacy. As of 2009they were planning on expanding and adding a horticultural therapyarea that contains a walking trail, a reflection pond, rock gardenand different landscape designs. The interior is done in a colorscheme similar to what one would find in a bed and breakfast:greens, oranges and other natural colors balanced with a woodfloor(Hammer, 2010).
Interior amenities include a theater styleclassroom and spirituality center, fitness center, nutrition station,cafe, computer labs, and lounge and study areas (Hammer, 2010). SheppardPratt’s hospital, located in Townsend Maryland, is a hospitalcomplex along with the new mental treatment facility that totals in240,000 square feet. The design objective was to provide quality carefor behavioral health patients. This is the first hospital in the USto have all private bedrooms.
The accessibility for patients andstaff is separate from that of the visitors, giving patients agreater sense of privacy and confidentiality. Using a dual corridorsystem also allows for the staff and patients to circulate withoutinterfering with public traffic creating an extra layer of safety.The sight lines from nurses stations cover all areas includingbedroom doors and common areas. The flexibility of the new unitallows for the change in room sizes as per the patients needs. Thedesign of the behavioral health care unit is for the patientsultimate goal of a shorter stay with effective treatment.
(Abbott,2004) Whenbuilding a new space, it is of the upmost importance to keep in mindthe patients safety, self harm and escape remain the two events thatdrive most of the safety related design choices in a behavioralhealth unit(Sine, 2009). 75% of inpatients suicides are by “Hanging”or anoxia. Anoxia is the lack of blood flow to the brain caused bytying something around the neck tightly enough to cut off blood flow(Hunt, 2014). 86% of those take place in a patients bedroom orbathroom(Hunt, 2014). 20% of patient deaths were from jumping fromthe building(Sine, 2009).
A study done in 2008 found that doors andwardrobes counted for 41% of the anchor points for hanging.(Sine,2009) Opportunities for self harm can be reduced by limiting ligatureattachment points or anchors,(Hunt, 2015) such as privacy curtainattachments, shower heads and drapes(Hammer, 2010). In order to avoidescapes the ability to lock the doors and choices of good securitysystems comes in handy. Door locks fall into two categories,Fail-safe and Fail-secure. Fail-safe locks provide automaticunlocking exits when the fire alarms are activated and Fail-securelocks have to be unlocked by a staff when alarms are activated.
(Hunt,2015)A full security system should be included in the design, thisentails having a digital recording system with cameras throughout thefacility.(Hammer, 2010) However, while keeping safety in mind it iseasy to fall into making a facility that feels and looks like aprison(Hunt, 2015). The way for a designer to avoid this is to havethe facility feel more like a home than a treatment center.
Anotherway to increase safety is to eliminate recesses, blind corners anddead ends in the walls. By doing so, one eliminates hiding spaces forstaff and patients. In order to do this, the designer can plan out awall to fill in the recess. This will allow for improved observation,safety and security and expand the reach of natural light as well asnourishing and open feeling throughout the space. Toavoid the feeling of entrapment, it is important to get theperspective of the healthcare providers to create a therapeuticenvironment.(Mourshed, 2012) A questionnaire given to healthcareproviders showed that the principle components identified werespatial maintenance and environmental design(Mourshed, 2012).It isalso valuable to ask the patients what they do and do not like.Interviews with adolescents led to the conclusion that they dislikedprimary colors, children toys, and small scale furniture.
(Huffcut,2010)) they also said that they would like to improve thedaylighting in the facility and they enjoyed cool colors of blue andpurple.(Huffcut, 2010) Behavioralhealthcare facilities include:diagnostic and treatment areas, dietic areas, supply, housekeeping,administrative, out patient and inpatient areas.(Carr, 2011) Clinical and administrative leaders, along with patients prefer amore residential design(deinstitutionalizing design). While no onecan agree what type of design is better(Sine, 2009), most peopleagree that the best approach considers the risk zones public areas,supervised patient treatments and activity rooms, and patientsolitude zones.(deinstitutionalizing design) When designing, onewants to first figure out the designated private areas, the seatingoptions, and how to increase daylight.(Huffcut,2010)) The design of the facility should also be chosenbetween a campus design or consolidated design.
A campus design, orpod design, is multiple areas with a main “street”, while aconsolidated design has everything in one area.(Sine, 2009) Circulationcan be either a three corridor circulation, or central circulation.They have to be carefully studied to have the correct width to lengthratios and give staff easy sight lines (deinstitutional design). Athree corridor circulation system is often used in a consolidateddesign. It separates staff patients and visitors. The staff is thenavailable to circulate between patients and support spaces, whilehaving easy access to “Offstage” areas (deinstitutionalizingdesign).
The “offstage areas allow for breaks and paperwork(deinstitutionalizing design). Central Circulation connectsclassrooms, treatment areas, dinning and social experiences for theentire Facility community.(deinstitutionalizing design) Thebiggest design challenge that accompanies pod design is to achieve aunit that is open and has good sight lines forstaff.(deinstitutionalizing design) The good thing about pod designis that it provides flexibility for changes in patient demographics,and each area can be designed to meet physical, psychological andsocial needs for several patient populations.(deinstituyinalizingdesign) For this reason, pod design has become more desirable and hasbeen used more frequently with modern institutions. Essentiallycentral circulation is a spine that leads throughout the space. Somefacilities that use central circulation have what they call “facilitymalls”, these house banks markets and salons.
(deinstitutionalizingdesign) The malls encourage patient interaction and help with thetransition from a facility to the real world. (deinstitutionalizingdesign) In both consolidated and campus design, nurses stationsshould be decentralized, and without barriers, allowing for betterobservation of the patients. Removing the glass or using frame freenurses station encourages interaction between patients and staff.However this will also require the staff to be comfortable working ina more open setting.
Inseclusion spaces, such as bedrooms, it is essential to remember thatit remain a refuge for the patients. The problem faced with thebedroom is keeping the feeling residential while safety and securitymeasures a properly set up. Outward swinging room doors helps keepsight lines open when staff is looking in on patients.
Having sensorsplaced on top of the patients bedroom and bathroom doors will alsohelp with safety measures, as they can alert staff if pressure isapplied to the top should a patient attempt suicide. In secludedzones there is a higher risk of self harm. Keeping this in mindfurnishings and finishes should be carefully selected. The furnitureshould be free of any sharp edges and be securely fastened to thewalls. It is also suggested that there be no doors or drawers on anyfurniture pieces. The use of damage resistant material will also helpavoid potential hazards, such as shatter proof non glass mirrors. Theceiling should be monolithic while seamlessly integrating sprinklers,heating and cooling, and security lighting. The colors patterns andtextures should be similar to those used in residential spaces.
Keepingquiet rooms and living rooms apart from seclusion spaces allowspatients to interact with each other or take a step away from thegroup if they feel overwhelmed. This also gives the patient an areato cool down and gain a grasp on what they feel(darcy). Using builtin seating in these areas help create safe levels of seclusion andallow for the impression of having a more private nook within thespace. However, using sound absorbing materials proves to bedifficult. This is because they tend to be more porous and softercreating a greater risk for infection. Largeopen areas such as social and group treatment areas are replacing theolder enclosed day rooms. When designing these spaces should bethought of as multipurpose spaces. Doing this allows for greaterflexibility for what is needed.
Curtains in this area should beremoved and replaced by blinds placed within the windows. Placingthe blinds between the glass denies access to the controls creating asafer environment. Finishes and furnishings for these areas should bedurable and safe, even though supervision and visibility of theseareas generally reduce patient risk. Public zones, such as theentrance or out-patient areas, can be furnished with similar thingsfound in a hospitality setting. The only caveat to this is to makesure the bathrooms are accessible to patients before or during theadmission process. Whenthinking of the finishes and furnishings for a Behavioral healthcarefacility it is critical to keep every surface in mind. One shouldalways be aware of how the floor is fixed to the walls and floorcoverings should be chosen with the safety of the patient in mind.
This includes the slip resistance texture and how easy it is toclean. Since the availability of solution dyed yarn and moistureresistant backing, broadloom carpeting has been widely used. Hardwoodor wood grained flooring will also create more of a residential feel.Walls are typically more difficult to have sound depletion propertiesbecause they are more susceptible to damage from use. Acousticceiling treatments can be used but not in seclusion rooms bedrooms orbathrooms. In the open areas or quiet rooms where they are allowedthe acoustic ceiling tiles and not allowed to be the typical lay intype.
This is because while reduced noise levels are very important,aggressive or disruptive behavior is often the staffs first clue to apatient’s escalating behavior. Thelighting in a Behavioral Healthcare facility should be well thoughtout. Such as the orientation of the building and how much daylightcertain rooms receive. Bedrooms for example should have a windowallowing for morning sun creating a connection between the time ofday and the seasons for the patient. The natural light also helpsestablish an open feeling within the space. Natural light also haspositive effects on patients, some experience shorter stays and morefavorable treatment outcomes.
The views provided by windows orpictures also increase positive feelings while anger and anxietydecrease. Theflaws faced in the past should teach designers how to build for thefuture. Using what we know and how it correlates to the health ofpatients give designers a greater opportunity to help. Having a podsystem a social aspect to the design of a behavioral healthcarefacility design will help teach patients how to deal with differentscenarios and their reactions.